Salvage of Infected Cardiac Implantable Electronic Device and Pregnancy Preservation Using CITA-MIS.

backgroundManaging pocket infections in cardiac implantable electronic devices (CIEDs) during early pregnancy presents significant clinical challenges, as current guidelines mandate complete system extraction. However, extraction carries high maternal-fetal risks, including surgical complications, radiation exposure, and teratogenic effects of systemic antibiotics. CASE SUMMARY: A 29-year-old woman, 5-week pregnant, was referred for a CIED pocket infection with an extruding implantable cardioverter-defibrillator implanted 9 years earlier for idiopathic ventricular fibrillation. Given the risks of extraction and the patient's desire to preserve her pregnancy, a conservative salvage approach integrating controlled in situ-targeted ultrahigh-concentration antibiotic administration with minimally invasive surgery was performed. The procedure involved limited surgical intervention, targeted antibiotic administration, and meticulous shielding to minimize fetal radiation exposure. Antibiotic levels were monitored daily, maintaining a mean vancomycin area under the concentration-time curve over 24 hours to minimum inhibitory concentration ratio of 31.7 (95% CI: 26.9-36.5) μg·hour/mL, ensuring effective infection control while minimizing systemic toxicity. The patient remained infection-free and underwent a successful cesarean delivery of a full-term healthy baby. WHY BEYOND THE GUIDELINES?: Current recommendations advocate complete CIED system removal for pocket infections; however, they do not address early pregnancy, where extraction may entail significant procedural, maternal, and fetal risks that could, in some cases, lead to consideration of pregnancy termination. This case highlights a safe and effective alternative, supporting the need for guideline expansion to include conservative salvage strategies in high-risk patients. TAKE-HOME MESSAGES: Controlled in situ-targeted ultrahigh-concentration antibiotic administration with minimally invasive surgery offers a safe and effective alternative for managing infected CIEDs in pregnancy, avoiding extraction-related risks, and minimizing maternal and fetal harm while maintaining high local antibiotic concentrations with minimal systemic exposure. Integrating area under the concentration-time curve over 24 hours to minimum inhibitory concentration-guided monitoring ensures precise dosing, reinforcing the need to expand guidelines to include conservative salvage options for high-risk patients.