Detailed bacteriologic tests to identify the origin of transvenous pacing system infections indicate a high prevalence of multiple organisms

Analysis of a 10-year period of lead removal in a referral centre

OBJECTIVES

Our goal was to analyse all lead extraction procedures (transvenous or open surgery) performed in our centre and the short- and long-term follow-up data from these patients.

METHODS

All lead extractions performed from 2008 to 2017 were retrospectively reviewed for patient characteristics and indications for device implantation; indications for lead extraction; techniques used; peri- and postprocedural complications and short- and long-term follow-up data.

RESULTS

A total of 159 patients (282 leads) were included [age 70 (62-78) years; 72% men]. The median follow-up time was 57 (25-90) months. Patients with lead explants were excluded. The most common indication for lead removal was infection (77%). A surgical approach was necessary in 14 patients (9%) owing to unsuccessful transvenous removal (n = 3), large vegetation in the lead (n = 4), concomitant valvular endocarditis (n = 2), other indications for open surgery (n = 4) and complicated transvenous removal (n = 1). Removal was tried for 282 leads. Of those, 256 were completely removed. Clinical success was achieved in 155 individual patients (98%). Complications occurred in 6 patients: 3 persistent infections, 1 stroke and 2 blood vessel ruptures. The procedure-related mortality rate was 2% (n = 3).

CONCLUSIONS

Lead removal was associated with a high success rate and low all-cause complication and mortality rates. Emergency surgery because of acute complications was rare, and open-heart surgery was most frequently elective and not associated with a worse outcome.

The Burden and Risk Factors for Infection of Transvenous Cardiovascular Implantable Electronic Device: a Nationwide Cohort Study

BACKGROUND AND OBJECTIVES

There are limited published data on the incidence and cost associated with cardiac implantable electrical device (CIED) infection for Asian patients. We analyzed the infection burden associated with the implantation of CIEDs in Korea.

METHODS

In the Health Insurance Review & Assessment Service (HIRA) database during the period from January 1, 2014 to December 31, 2016, we identified 16,908 patients with CIED implantation. CIED infection was defined as either: 1) Infection-related diagnosis code by the Korean Standard Classification of Diseases after any CIED procedure; or 2) CIED removal along with systemic infection.

RESULTS

The proportions of first implantation and replacement were 77.6% and 22.4%, respectively. During the follow-up period of 17.1±10.6 months, a total of 462 patients had CIED infection with incidence of 1.95 per 100 person-years with higher infection rate in replacement than first implantation (3.97 vs. 1.4 per 100 person-years, p<0.001). The average cost per person was US$ 16,584 (pacemaker, $13,736; implantable cardioverter defibrillator, $28,402; cardiac resynchronization therapy, $29,674). The risk factors of CIED infection were generator replacement (adjusted hazard ratio [aHR], 3.14; 95% confidence interval [CI], 2.60-3.78), diabetes mellitus (aHR, 1.94; 95% CI, 1.58-2.38), and congestive heart failure (aHR, 1.86; 95% CI, 1.51-2.28).

CONCLUSIONS

The rate of CIED infection in Korea was 1.95 per 100 person-years with average cost of US$ 16,584. The most important risk factor was generator replacement. This result suggests that generator replacement should be performed cautiously to avoid CIED infection.

Superior Vena Cava Thrombosis after Intravascular AICD Lead Extraction: A Case Report

Pacemaker lead extraction has been shown to be an effective and safe treatment in the case of infected permanent pacemaker leads. However, it can lead to potentially serious complications, usually occurring during the extraction procedure. This report describes a case of a 74-year-old male with a persistent superior vena cava thrombosis related to an infected permanent pacemaker lead transvenous extraction. Clinical and surgical management are discussed.

Remnant Pacemaker Lead Tips after Lead Extractions in Pacemaker Infections

Complete hardware removal is recommended in the case of patients with cardiovascular implantable electronic device (CIED) infections. However, the complete extraction of chronically implanted leads is not always achieved. The outcomes and optimal management of CIED infections with retained material after lead extractions have not been elucidated. In this case report, we present five patients with CIED infections with remnant lead tips even after lead extractions. Two patients had localized pocket infections, and were managed with antibiotics for a period of more than two weeks. The other three patients had infective endocarditis, and were managed with antibiotics for a period of more than four weeks. In one patient, the lead tip migrated to the right pulmonary artery, but did not produce any symptoms or complications. Only one of five patients experienced a resurgence of an infection.

Analysis of extracted cardiac device leads for bacteria type: clinical impact

The use of cardiac implantable electronic devices (CIED) increased over time, followed by rise of CIED-related complications, mainly infections and malfunctions. A clear diagnosis of CIED infection is of pivotal importance. When infection is confirmed, transvenous lead extraction (TLE) becomes mandatory, with associated risks and mortality. Local lesions at the device pocket often return negative swabs and tissue specimens, but conservative interventions are inconclusive, raising risks of systemic dissemination of infection and difficulties of subsequent TLE any more. When local bacteriological analyses are positive, once again, a contamination effect cannot be excluded. So traditional local swabs and tissue specimens exhibit low sensitivity and specificity for diagnosis of CIED infection. On the contrary, in cases sepsis, blood samples show high specificity, while the sensibility remains low, due to possible negative results in patients on antibiotics. In this scenario, the analysis of extracted device leads seems more appropriate for diagnostic purposes.

Infection after pacemaker implantation: infection rates and risk factors associated with infection in a population-based cohort study of 46299 consecutive patients

Aims

Infection is a serious complication of pacemaker (PM) systems. Although the rate of infection has been debated, the figures are largely unknown. We therefore studied the incidence of PM infection and its associated risk factors in the Danish population.

Methods and results

Since 1982, all PM implantation and removal procedures performed in Denmark have been prospectively recorded in the Danish Pacemaker Register. All patients (n = 46299) who underwent implantation between 1982 and 2007 were included. The total length of surveillance was 236 888 PM-years. The incidence of infection was calculated according to the total number of PM-years. The incidence of surgical site infection (≤365 days after PM implantation) was compared with later infection in first implant and replacement procedures. Multiple-record and multiple-event-per-subject proportional hazards analyses were used to identify the independent risk factors of PM infection. Surgical site infection occurred in 192 cases after first implantation (incidence rate 4.82/1000 PM-years), and in 133 cases after replacement (12.12/1000 PM-years). Infections occurring more than 365 days after the first implantation occurred in 153 cases (1.02/1000 PM-years), and in 118 cases after replacement (3.26/1000 PM-years). Independent factors associated with an increased risk of PM infection were a greater number of PM operations (including replacements), male sex, younger age, implantation during the earliest part of the study period, and absence of antibiotics (P< 0.001).

Conclusion

The overall risk of infection after PM implantation was low. A greater number of operations augmented the risk of infection. This should be taken into account when considering revisions of PM systems.

New perspectives of infections in cardiovascular disease

Infections have been recognized as significant causes of cardiac diseases for many decades. Various microorganisms have been implicated in the etiology of these diseases involving all classes of microbial agents. All components of the heart structure can be affected by infectious agents, i.e. pericardium, myocardium, endocardium, valves, autonomic nervous system, and some evidence of coronary arteries. A new breed of infections have evolved over the past three decades involving cardiac implants and this group of cardiac infectious complications will likely continue to increase in the future, as more mechanical devices are implanted in the growing ageing population. This article will review the progress made in the past decade on understanding the pathobiology of these infectious complications of the heart, through advances in genomics and proteomics, as well as potential novel approach for therapy.An up-to-date, state-of-the-art review and controversies will be outlined for the following conditions: (i) perimyocarditis; (ii) infective endocarditis; (iii) cardiac device infections; (iv) coronary artery disease and potential role of infections.

A case of permanent pacemaker lead infection

BACKGROUND

A 70-year-old man with diabetes mellitus, fever of unknown origin and oliguria was admitted to hospital. Blood cultures were positive for a Staphylococcus aureus infection and antibiotic therapy was started. A year previously the patient had received a DDD pacemaker to treat sick sinus syndrome with intermittent atrioventricular block. Transthoracic echocardiography showed severe tricuspid regurgitation and a mass attached to the ventricular pacemaker lead; transesophageal echocardiography showed the same finding but additionally showed a vegetation on the tricuspid septal leaflet and a mass attached to the atrial pacemaker lead. Coronary angiography revealed a lesion that occluded 70% of the proximal left anterior descending artery and occlusion of the proximal right coronary artery.

INVESTIGATIONS

Electrocardiography, transthoracic echocardiography, transesophageal echocardiography, multidetector thoracic CT, coronary angiography, blood cultures and laboratory testing.

DIAGNOSIS

Pacemaker lead infection and tricuspid valve endocarditis.

MANAGEMENT

The patient was surgically treated under cardiopulmonary bypass during which the pacemaker system was removed and an accurate debridement of the tricuspid tissue was performed.

[Non-valvular cardiac devices endocarditis]

The risk of infective endocarditis on pacemaker or ICD is not negligible and has increased in recent years. Several host-related, procedure-related, or device-related risk factors have been recognized. Owing to its potential severity, the possibility of infective endocarditis should be envisaged in patients with repeated pulmonary infections or documented bacteremia and transesophageal echocardiography should then be used. The most common germs causing pacemaker endocarditis are staphylococci. Treatment requires prolonged antibiotic therapy and retrieval of the pacemaker and leads.

Management and outcome of permanent pacemaker and implantable cardioverter-defibrillator infections

OBJECTIVES

We describe the management and outcome of permanent pacemaker (PPM) and implantable cardioverter-defibrillator (ICD) infections in a large cohort of patients seen at a tertiary care facility with expertise in device lead extraction.

BACKGROUND

Infection is a serious complication of PPM and ICD implantation. Optimal care of patients with these cardiac device infections (CDI) is not well defined.

METHODS

A retrospective review of all patients with CDI admitted to Mayo Clinic Rochester between January 1, 1991, and December 31, 2003, was conducted. Demographic and clinical data were collected, and descriptive analysis was performed.

RESULTS

A total of 189 patients met the criteria for CDI (138 PPM, 51 ICD). The median age of the patients was 71.2 years. Generator pocket infection (69%) and device-related endocarditis (23%) were the most common clinical presentations. Coagulase-negative staphylococci and Staphylococcus aureus, in 42% and 29% of cases, respectively, were the leading pathogens for CDI. Most patients (98%) underwent complete device removal. Duration of antibiotic therapy after device removal was based on clinical presentation and causative organism (median duration of 18 days for pocket infection vs. 28 days for endocarditis; 28 days for S. aureus infection vs. 14 days for coagulase-negative staphylococci infection [p < 0.001]). Median follow-up after hospital discharge was 175 days. Ninety-six percent of patients were cured with both complete device removal and antibiotic administration.

CONCLUSIONS

Cure of CDI is achievable in the large majority of patients treated with an aggressive approach of combined antimicrobial treatment and complete device removal. Based on findings of our large retrospective institutional survey and previously published data, we submit proposed management guidelines of CDI.