Pacemaker infective endocarditis

Cardiovascular Implantable Electronic Device Infections: A Contemporary Review

Infections associated with cardiac implantable electronic devices (CIEDs) are increasing and are a cause of significant morbidity and mortality. This article summarizes the latest updates with respect to the epidemiology, microbiology, and risk factors for CIED-related infections. It also covers important considerations regarding the diagnosis, management, and prevention of these infections. Newer technologies such as leadless pacemakers and subcutaneous implantable cardioverters and defibrillators are discussed.

18F-FDG PET/CT and Radiolabeled Leukocyte SPECT/CT Imaging for the Evaluation of Cardiovascular Infection in the Multimodality Context: ASNC Imaging Indications (ASNC I2) Series Expert Consensus Recommendations From ASNC, AATS, ACC, AHA, ASE, EANM, HRS, IDSA, SCCT, SNMMI, and STS

This document on cardiovascular infection, including infective endocarditis, is the first in the American Society of Nuclear Cardiology Imaging Indications (ASNC I2) series to assess the role of radionuclide imaging in the multimodality context for the evaluation of complex systemic diseases with multisocietal involvement including pertinent disciplines. A rigorous modified Delphi approach was used to determine consensus clinical indications, diagnostic criteria, and an algorithmic approach to diagnosis of cardiovascular infection including infective endocarditis. Cardiovascular infection incidence is increasing and is associated with high morbidity and mortality. Current strategies based on clinical criteria and an initial echocardiographic imaging approach are effective but often insufficient in complicated cardiovascular infection. Radionuclide imaging with fluorine-18 fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (CT) and single photon emission computed tomography/CT leukocyte scintigraphy can enhance the evaluation of suspected cardiovascular infection by increasing diagnostic accuracy, identifying extracardiac involvement, and assessing cardiac implanted device pockets, leads, and all portions of ventricular assist devices. This advanced imaging can aid in key medical and surgical considerations. Consensus diagnostic features include focal/multifocal or diffuse heterogenous intense 18F-FDG uptake on valvular and prosthetic material, perivalvular areas, device pockets and leads, and ventricular assist device hardware persisting on non-attenuation corrected images. There are numerous clinical indications with a larger role in prosthetic valves, and cardiac devices particularly with possible infective endocarditis or in the setting of prior equivocal or non-diagnostic imaging. Illustrative cases incorporating these consensus recommendations provide additional clarification. Future research is necessary to refine application of these advanced imaging tools for surgical planning, to identify treatment response, and more.

18F-FDG PET/CT and radiolabeled leukocyte SPECT/CT imaging for the evaluation of cardiovascular infection in the multimodality context: ASNC Imaging Indications (ASNC I2) Series Expert Consensus Recommendations from ASNC, AATS, ACC, AHA, ASE, EANM, HRS, IDSA, SCCT, SNMMI, and STS

This document on cardiovascular infection, including infective endocarditis, is the first in the American Society of Nuclear Cardiology Imaging Indications (ASNC I2) series to assess the role of radionuclide imaging in the multimodality context for the evaluation of complex systemic diseases with multi-societal involvement including pertinent disciplines. A rigorous modified Delphi approach was used to determine consensus clinical indications, diagnostic criteria, and an algorithmic approach to diagnosis of cardiovascular infection including infective endocarditis. Cardiovascular infection incidence is increasing and is associated with high morbidity and mortality. Current strategies based on clinical criteria and an initial echocardiographic imaging approach are effective but often insufficient in complicated cardiovascular infection. Radionuclide imaging with 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (CT) and single photon emission computed tomography/CT leukocyte scintigraphy can enhance the evaluation of suspected cardiovascular infection by increasing diagnostic accuracy, identifying extracardiac involvement, and assessing cardiac implanted device pockets, leads, and all portions of ventricular assist devices. This advanced imaging can aid in key medical and surgical considerations. Consensus diagnostic features include focal/multi-focal or diffuse heterogenous intense 18F-FDG uptake on valvular and prosthetic material, perivalvular areas, device pockets and leads, and ventricular assist device hardware persisting on non-attenuation corrected images. There are numerous clinical indications with a larger role in prosthetic valves, and cardiac devices particularly with possible infective endocarditis or in the setting of prior equivocal or non-diagnostic imaging. Illustrative cases incorporating these consensus recommendations provide additional clarification. Future research is necessary to refine application of these advanced imaging tools for surgical planning, to identify treatment response, and more.

18F-FDG PET/CT and radiolabeled leukocyte SPECT/CT imaging for the evaluation of cardiovascular infection in the multimodality context: ASNC Imaging Indications (ASNC I2) Series Expert Consensus Recommendations from ASNC, AATS, ACC, AHA, ASE, EANM, HRS, IDSA, SCCT, SNMMI, and STS

This document on cardiovascular infection, including infective endocarditis, is the first in the American Society of Nuclear Cardiology Imaging Indications (ASNC I2) series to assess the role of radionuclide imaging in the multimodality context for the evaluation of complex systemic diseases with multi-societal involvement including pertinent disciplines. A rigorous modified Delphi approach was used to determine consensus clinical indications, diagnostic criteria, and an algorithmic approach to diagnosis of cardiovascular infection including infective endocarditis. Cardiovascular infection incidence is increasing and is associated with high morbidity and mortality. Current strategies based on clinical criteria and an initial echocardiographic imaging approach are effective but often insufficient in complicated cardiovascular infection. Radionuclide imaging with 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (CT) and single photon emission computed tomography/CT leukocyte scintigraphy can enhance the evaluation of suspected cardiovascular infection by increasing diagnostic accuracy, identifying extracardiac involvement, and assessing cardiac implanted device pockets, leads, and all portions of ventricular assist devices. This advanced imaging can aid in key medical and surgical considerations. Consensus diagnostic features include focal/multi-focal or diffuse heterogenous intense 18F-FDG uptake on valvular and prosthetic material, perivalvular areas, device pockets and leads, and ventricular assist device hardware persisting on non-attenuation corrected images. There are numerous clinical indications with a larger role in prosthetic valves, and cardiac devices particularly with possible infective endocarditis or in the setting of prior equivocal or non-diagnostic imaging. Illustrative cases incorporating these consensus recommendations provide additional clarification. Future research is necessary to refine application of these advanced imaging tools for surgical planning, to identify treatment response, and more.

Risk of infections related to endovascular catheters and cardiac implantable devices in hemodialysis patients

Patients requiring dialysis are extremely vulnerable to infectious diseases. The high burden of comorbidities and weakened immune system due to uremia and previous immunosuppressive therapy expose the patient on dialysis to more infectious events than the general population. The infectious risk is further increased by the presence of endovascular catheters and implantable cardiologic devices. The former is generally placed as urgent vascular access for dialysis and in subjects requiring hemodialysis treatments without autogenous arteriovenous fistula. The high frequency of cardiovascular events also increases the likelihood of implanting indwelling implantable cardiac devices (CIED) such as pacemakers (PMs) and defibrillators (ICDs). The simultaneous presence of CVC and CIED yields an increased risk of developing severe prosthetic device-associated bloodstream infections often progressing to septicemia. Although, antibiotic therapy is the mainstay of prosthetic device-related infections, antibiotic resistance of biofilm-residing bacteria reduces the choice of infection eradication. In these cases, the resolution of the infection process relies on the removal of the prosthetic device. Compared to CVC removal, the extraction of leads is a more complex procedure and poses an increased risk of vessel tearing. As a result, the prevention of prosthetic device-related infection is of utmost importance in hemodialysis (HD) patients and relies principally on avoiding CVC as vascular access for HD and placement of a new class of wireless implantable medical devices. When the combination of CVC and CIED is inevitable, prevention of infection, mainly due translocation of skin bacteria, should be a mandatory priority for healthcare workers.

18F-FDG PET/CT and radiolabeled leukocyte SPECT/CT imaging for the evaluation of cardiovascular infection in the multimodality context: ASNC Imaging Indications (ASNC I2) Series Expert Consensus Recommendations from ASNC, AATS, ACC, AHA, ASE, EANM, HRS, IDSA, SCCT, SNMMI, and STS

This document on cardiovascular infection, including infective endocarditis, is the first in the American Society of Nuclear Cardiology Imaging Indications (ASNC I2) series to assess the role of radionuclide imaging in the multimodality context for the evaluation of complex systemic diseases with multi-societal involvement including pertinent disciplines. A rigorous modified Delphi approach was used to determine consensus clinical indications, diagnostic criteria, and an algorithmic approach to diagnosis of cardiovascular infection including infective endocarditis. Cardiovascular infection incidence is increasing and is associated with high morbidity and mortality. Current strategies based on clinical criteria and an initial echocardiographic imaging approach are effective but often insufficient in complicated cardiovascular infection. Radionuclide imaging with 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) and single photon emission computed tomography/CT leukocyte scintigraphy can enhance the evaluation of suspected cardiovascular infection by increasing diagnostic accuracy, identifying extracardiac involvement, and assessing cardiac implanted device pockets, leads, and all portions of ventricular assist devices. This advanced imaging can aid in key medical and surgical considerations. Consensus diagnostic features include focal/multi-focal or diffuse heterogenous intense 18F-FDG uptake on valvular and prosthetic material, perivalvular areas, device pockets and leads, and ventricular assist device hardware persisting on non-attenuation corrected images. There are numerous clinical indications with a larger role in prosthetic valves, and cardiac devices particularly with possible infective endocarditis or in the setting of prior equivocal or non-diagnostic imaging. Illustrative cases incorporating these consensus recommendations provide additional clarification. Future research is necessary to refine application of these advanced imaging tools for surgical planning, to identify treatment response, and more.

Septic Pulmonary Embolism: A Contemporary Profile

Septic pulmonary embolism (SPE) is a rare clinical entity that is distinct from the classic and more common non-septic thrombotic pulmonary embolism. SPE should be suspected in patients with a systemic acute inflammatory reaction or sepsis who develop signs and symptoms of pulmonary involvement. The diagnosis of SPE depends on the specific radiologic finding of multiple, peripheral, nodular, possibly cavitated lesions. SPE should prompt an immediate search for the primary source of infection; typically, right-sided infective endocarditis, cardiac implantable electronic devices, and septic thrombophlebitis as a complication of bone, skin, and soft tissue infection including Lemierre's syndrome, indwelling catheters, or direct inoculation via injection drug use. Invasive treatment of the infection source may be necessary; in thrombophlebitis, the efficacy and safety of anticoagulation remain undefined. Blood cultures may be negative, particularly among patients with recent antibiotic exposure, and broad-spectrum antimicrobial therapy should be considered. The in-hospital mortality of SPE ranges up to 20% in published case series. While trends in the incidence of SPE are unknown, the opioid epidemic, the growing use of cardiac implantable electronic devices worldwide, and the reported increase in cases of septic thrombophlebitis may be leading to an escalation in SPE cases. We provide a contemporary profile of SPE and propose a clinical management algorithm in patients with suspected or confirmed SPE.

Clinical Approach to Evaluation of Underlying Cardiac Device Infection in Patients Hospitalized with Bacteremia

More than 400,000 cardiac implantable electronic devices (CIEDs), including permanent pacemakers, implantable cardioverter-defibrillators, and cardiac resynchronization therapy devices, are implanted every year in the United States (US). Infection is a serious complication of CIED therapy and is associated with high morbidity and mortality. While CIED pocket infection can be diagnosed based on clinical exam findings, positive blood culture may be the only manifestation of CIED lead infection. Thus, management of bacteremia in patients living with CIEDs requires special consideration. This review summarizes contemporary data in the context of the recently updated 2023 Duke-International Society for Cardiovascular Infectious Diseases Criteria for Infective Endocarditis. We have synthesized these data into an algorithmic approach to streamline the diagnostic evaluation of CIED infection in patients presenting with bacteremia.

Radionuclide Imaging of Infective Endocarditis

Infective endocarditis (IE) is associated with high morbidity and mortality. Early diagnosis is crucial for adequate patient management. Due to difficulties in the diagnosis, a multidisciplinary discussion in addition to the integration of clinical signs, microbiology data, and imaging data is used. Imaging, including echocardiography, molecular imaging techniques, and coronary CT angiography (CTA) is central to detect infections involving heart valves and implanted cardiovascular devices, also allowing for early detection of septic emboli and metastatic. This article describes the main clinical application of white blood cell SPECT/CT and [¹⁸F]FDG-PET/CT and CTA in IE and infections associated with cardiovascular implantable electronic devices.

Current Views on Infective Endocarditis: Changing Epidemiology, Improving Diagnostic Tools and Centering the Patient for Up-to-Date Management

Infective endocarditis (IE) is a rare but potentially life-threatening disease, sometimes with longstanding sequels among surviving patients. The population at high risk of IE is represented by patients with underlying structural heart disease and/or intravascular prosthetic material. Taking into account the increasing number of intravascular and intracardiac procedures associated with device implantation, the number of patients at risk is growing too. If bacteremia develops, infected vegetation on the native/prosthetic valve or any intracardiac/intravascular device may occur as the final result of invading microorganisms/host immune system interaction. In the case of IE suspicion, all efforts must be focused on the diagnosis as IE can spread to almost any organ in the body. Unfortunately, the diagnosis of IE might be difficult and require a combination of clinical examination, microbiological assessment and echocardiographic evaluation. There is a need of novel microbiological and imaging techniques, especially in cases of blood culture-negative. In the last few years, the management of IE has changed. A multidisciplinary care team, including experts in infectious diseases, cardiology and cardiac surgery, namely, the Endocarditis Team, is highly recommended by the current guidelines.

Infective endocarditis of transcatheter atrial septal occluder devices: A case report

Learning objective

Adherence to diagnostic and therapeutic practice guidelines for suspected cardiac implantable electronic device infections

BACKGROUND

Despite guidelines describing the optimal diagnostic and therapeutic procedures for patients with suspected cardiac implantable electronic device (CIED) infections, their management is often challenging.

AIMS

To describe our diagnostic and therapeutic practices for suspected CIED infection, and to compare them with European Heart Rhythm Association (EHRA) guidelines.

METHODS

Patients hospitalized in the tertiary care Nancy University Hospital for suspected CIED infection from 2014 to 2019 were included retrospectively. We applied the EHRA classification of CIED infection, and compared diagnostic and therapeutic management with the EHRA guidelines.

RESULTS

Among 184 patients (mean age 72.3±12.4 years), 137 had a proven infection of the lead (by transthoracic echocardiography/transoesophageal echocardiography, ¹⁸F-fluorodesoxyglucose positron emission tomography/computed tomography or positive culture of the lead) or an isolated pocket infection without proof of lead infection, and 47 had no proof of CIED infection. According to the EHRA classification, CIED infection was considered as definite in 145 patients and possible in 31 and was excluded in eight patients. Regarding recommended diagnostic procedures, blood cultures were performed in 90.8%, transthoracic echocardiography in 97.8%, transoesophageal echocardiography in 85.9%, ¹⁸F-fluorodesoxyglucose positron emission tomography/computed tomography in 50.5% and imaging for embolisms in 78.3% of the patients. Compared with therapeutic recommendations for the 145 cases of definite CIED infection, device removal was performed in 96 patients (66.2%) and antibiotic therapy was prescribed in 130 (89.7%), with a duration equal to or longer than that recommended in 105 (72.4%) of the patients.

CONCLUSION

This study underlines the difficulties in following theoretical guidelines in daily practice, where both technical and human considerations interfere with their strict appliance.

Long-term outcomes of non-systematic device reimplantation following lead extraction in selected patients

Following the removal of cardiovascular implantable electronic devices (CIEDs), reassessment of the need for a new device is vital. Some patients may have exhibited an improvement in rhythm or cardiac function and may thus no longer meet the guideline requirements for reimplantation. However, the long-term outcomes of non-systematic device reimplantation remain unknown. In the present study, it was hypothesized that the implantation of pacing systems in selected patients following lead extraction is safe. In order to confirm this hypothesis, a total of 854 patients (aged between 28 and 82 years) who underwent the removal of a CIED were enrolled in the present study and they were all reassessed to determine whether a new device following lead extraction was necessary. In order to determine which patients would undergo non-systematic device reimplantation, the standard guidelines, the criteria and the wishes of the patient were all taken into consideration. Patients remained device-free unless an adverse clinical event occurred that required reimplantation. The primary study endpoint was the rate of sudden death or reimplantation. Between January, 2014 and December, 2019, 854 consecutive patients underwent pacing system extraction, of whom 210 patients (24.6%) underwent non-systematic device reimplantation following careful reassessment (the non-reimplantation group). Among the 210 patients, 162 (77.1%) were fitted with pacemakers, 26 (12.4%) underwent cardiac resynchronization therapy or cardiac resynchronization therapy-defibrillator and 22 (10.5%) were implanted with a cardioverter-defibrillator. During a mean follow-up period of 40.4 months, 86 patients reached the primary endpoint of the study, including 54 out of 210 patients (25.7%) who experienced an adverse clinical event that required reimplantation and 32 out of 210 patients (15.2%) who experienced sudden death. Reimplantation of a new device was not required in ~25% of the patients. On the whole, the present study demonstrates that following pacing system removal, non-systematic device reimplantation associated with close surveillance is safe for selected patients.

European Heart Rhythm Association (EHRA) international consensus document on how to prevent, diagnose, and treat cardiac implantable electronic device infections-endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), the Latin American Heart Rhythm Society (LAHRS), International Society for Cardiovascular Infectious Diseases (ISCVID) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS)

Pacemakers, implantable cardiac defibrillators, and cardiac resynchronization therapy devices are potentially life-saving treatments for a number of cardiac conditions, but are not without risk. Most concerning is the risk of a cardiac implantable electronic device (CIED) infection, which is associated with significant morbidity, increased hospitalizations, reduced survival, and increased healthcare costs. Recommended preventive strategies such as administration of intravenous antibiotics before implantation are well recognized. Uncertainties have remained about the role of various preventive, diagnostic, and treatment measures such as skin antiseptics, pocket antibiotic solutions, anti-bacterial envelopes, prolonged antibiotics post-implantation, and others. Guidance on whether to use novel device alternatives expected to be less prone to infections and novel oral anticoagulants is also limited, as are definitions on minimum quality requirements for centres and operators and volumes. Moreover, an international consensus document on management of CIED infections is lacking. The recognition of these issues, the dissemination of results from important randomized trials focusing on prevention of CIED infections, and observed divergences in managing device-related infections as found in an European Heart Rhythm Association worldwide survey, provided a strong incentive for a 2019 International State-of-the-art Consensus document on risk assessment, prevention, diagnosis, and treatment of CIED infections.

European Heart Rhythm Association (EHRA) international consensus document on how to prevent, diagnose, and treat cardiac implantable electronic device infections-endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), the Latin American Heart Rhythm Society (LAHRS), International Society for Cardiovascular Infectious Diseases (ISCVID) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS)

Pacemakers, implantable cardiac defibrillators, and cardiac resynchronization therapy devices are potentially life-saving treatments for a number of cardiac conditions, but are not without risk. Most concerning is the risk of a cardiac implantable electronic device (CIED) infection, which is associated with significant morbidity, increased hospitalizations, reduced survival, and increased healthcare costs. Recommended preventive strategies such as administration of intravenous antibiotics before implantation are well recognized. Uncertainties have remained about the role of various preventive, diagnostic, and treatment measures such as skin antiseptics, pocket antibiotic solutions, anti-bacterial envelopes, prolonged antibiotics post-implantation, and others. Guidance on whether to use novel device alternatives expected to be less prone to infections and novel oral anticoagulants is also limited, as are definitions on minimum quality requirements for centres and operators and volumes. Moreover, an international consensus document on management of CIED infections is lacking. The recognition of these issues, the dissemination of results from important randomized trials focusing on prevention of CIED infections, and observed divergences in managing device-related infections as found in an European Heart Rhythm Association worldwide survey, provided a strong incentive for a 2019 International State-of-the-art Consensus document on risk assessment, prevention, diagnosis, and treatment of CIED infections.

A Review of Cardiac Implantable Electronic Device Infections for the Practicing Electrophysiologist

Cardiovascular implantable electronic device (CIED) infections are morbid, costly, and difficult to manage. This review explores the pathophysiology, diagnosis, and management of CIED infections. Diagnostic accuracy has been improved through increased awareness and improved imaging strategies. Pocket or bloodstream infection with virulent organisms often requires complete system extraction. Emerging prophylactic interventions and novel devices have expanded preventative strategies and options for re-implantation. A clear and nuanced understanding of CIED infection is important to the practicing electrophysiologist.

European Heart Rhythm Association (EHRA) international consensus document on how to prevent, diagnose, and treat cardiac implantable electronic device infections-endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), the Latin American Heart Rhythm Society (LAHRS), International Society for Cardiovascular Infectious Diseases (ISCVID), and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS)

Pacemakers, implantable cardiac defibrillators, and cardiac resynchronization therapy devices are potentially lifesaving treatments for a number of cardiac conditions but are not without risk. Most concerning is the risk of a cardiac implantable electronic device (CIED) infection, which is associated with significant morbidity, increased hospitalizations, reduced survival, and increased health care costs. Recommended preventive strategies such as administration of intravenous antibiotics before implantation are well-recognized. Uncertainties have remained about the role of various preventive, diagnostic, and treatment measures such as skin antiseptics, pocket antibiotic solutions, antibacterial envelopes, prolonged antibiotics post-implantation, and others. When compared with previous guidelines or consensus statements, the present consensus document gives guidance on the use of novel device alternatives, novel oral anticoagulants, antibacterial envelopes, prolonged antibiotics post-implantation, as well as definitions on minimum quality requirements for centres and operators and volumes. The recognition that an international consensus document focused on management of CIED infections is lacking, the dissemination of results from new important randomized trials focusing on prevention of CIED infections, and observed divergences in managing device-related infections as found in an European Heart Rhythm Association worldwide survey, provided a strong incentive for a Novel 2019 International State-of-the-art Consensus document on risk assessment, prevention, diagnosis, and treatment of CIED infections.

Evidence-Based Strategies to Promote Long-Term Cardiac Implant Site Health: Review of the Literature

Cardiac implantable electronic devices (CIEDs) are commonly used nowadays. The association between CIED placement and infections is responsible for the high mortality and device explantation rate. Since CIED placement has increased in the past decade, CIED-related complications have risen. In order to reduce the CIED-related complications rate, the prevention of device infection represents the main goal. Over time, many different studies have proven the importance of the measures to prevent CIED-related infections. This review aims to collect the actual recommendations for CIED infection prevention, providing an overview of the main evidence-based strategies.

A Rare Entity-Percutaneous Lead Extraction in a Very Late Onset Pacemaker Endocarditis: Case Report and Review of Literature

The number of infections related to cardiac implantable electronic devices (CIEDs) has increased as the number of devices implanted around the world has grown exponentially in recent years. CIED complications can sometimes be difficult to diagnose and manage, as in the case of lead-related infective endocarditis. We present the case of a 48-year-old male diagnosed with Staphylococcus aureus device-related infective endocarditis, 12 years after the implant of a single chamber pacemaker. A recent history of the patient includes two urinary catheterizations due to obstructive uropathy in the context of a prostatic adenoma, 2 months previously, both without antibiotic prophylaxis; no other possible entry sites were found and no history of other invasive procedures. After initiation of antibiotic therapy according to antibiotic susceptibility testing, we decided to remove the right ventricular passive fixation lead along with the vegetation and pacemaker generator; because of severe lead adhesions in the costoclavicular region, and especially in the right ventricle, we needed mechanical sheaths to remove the abundant fibrous tissue that encompassed the lead. After a difficult, but successful, lead extraction along with a large vegetation and 6 weeks' antibiotic therapy, the clinical and biological evolution was favorable, without reappearance of symptoms. While very late lead endocarditis is a rarity, late lead-related infective endocarditis (more than 12 months elapsed since implant) is not an exception; this is why we find that endocarditis prophylaxis should be reconsidered in certain patient categories, our patient being proof that procedures with neglectable endocarditis risk according to the guidelines can lead to bacterial endocarditis.

Cardiac implantable electronic device infection: Does the device need to be extracted?

Background

Cardiac implantable electronic devices (CIED) have become a common treatment modality in clinical practice. The increase in utilization of these devices has been associated with an increase in infection rates. Published guidelines define when a device is deemed infected (CDI); recommendations for the work‐up of CDI and criteria for extraction. Few data exist as to adherence to these guidelines.

Objective

We wanted to o evaluate whether devices diagnosed as CDI fit guidelines, whether clinicians followed work‐up recommendation of CDI, and whether CIED was extracted according to the guidelines criteria in our hospital.

Methods

A retrospective review was performed in our hospital between 2008 and 2017. Adult patients (pts) 18 years and older who had their device extracted (DE) with a diagnosis of CDI were included. A total of 95 pts were identified.

Results

We included 95 pts who were diagnosed as having CDI and who had their DE. Work‐up of patients with a diagnosis of CDI was inconsistently followed. Blood cultures, Echocardiogram, lead cultures (LC), and device pocket cultures (PC) were done in 100%, 90.5%, 75.6%, and 49.3%, respectively. Thirty out of 90 pts. (33%) did not meet guidelines criteria for extraction.

Conclusions

In our institution, a one third of the pts diagnosed with CDI who had DE had no indication for DE per guidelines recommendations. Clinicians did not follow recommendations for work‐up of CDI consistently. Low adherence was seen in obtaining LC and PC. CIED extraction guidelines should be followed to prevent unnecessary complications and cost.

Candidemia in patients with cardiovascular implantable electronic devices

PURPOSE

Current guidelines recommend complete extraction of cardiovascular implantable electronic devices (CIEDs) in the case of persistent or recurrent fungemia without other identifiable sources, though supporting evidence is lacking. We sought to evaluate the prognosis of patients with candidemia and CIEDs.

METHODS

Twelve consecutive patients (54 ± 12 years, 8 male) with CIED and concurrent candidemia were reviewed.

RESULTS

At the time of diagnosis with candidemia, seven patients were immunocompromised, six were on long-term antibacterial therapy, two were intravenous drug users, four were on chronic hemodialysis, and six had a central venous catheter. Four patients were confirmed as definite CIED infection as vegetation was visible on lead by echocardiogram. The other 8 patients were considered possible CIED infection with candidemia of unknown focus. All patients with visible vegetation underwent CIED removal without complications, and other patients were initially managed non-operatively. After 1 year of follow-up, 7 patients had died and at extended follow-up, all patients without lead removal died while 3 of 4 patients with lead extraction survived. Of note, 50% of deaths in the patients without lead removal were associated with fungal sepsis.

CONCLUSIONS

Candida fungemia is associated with a high mortality. CIED removal should be an early consideration in these patients even if lead vegetations are not seen.

Multisystem organ failure secondary to Haemophilus parainfluenzae infective endocarditis on an ICD lead: A case report

Infection of implanted cardiac devices (ICD) is an unusual but life threatening event, rarely caused by Haemophilus parainfluenzae. While clinical presentation varies widely, infective endocarditis (IE) involving an ICD lead requires aggressive resuscitation and a multidisciplinary approach. We present a case of a 33-year-old intravenous drug user who presented in multisystem organ failure secondary to infective endocarditis on an ICD lead. This patient had a complicated hospital course requiring removal of her ICD, highlighting the dramatic presentation of this clinical state.

Candida tropicalis defibrillator endocarditis: A case report and review of current literature

We provide a review of current literature and report on a case of electronic device infective endocarditis with C. tropicalis. A 64-year-old man presented for revision of his implantable cardioverter defibrillator. Echocardiography revealed extensive vegetations attached to the Eustachian valve and in the right ventricular apex. Microbiological findings presented C. tropicalis on the explanted material. The patient refused additional surgical intervention. We successfully treated the patient with liposomal Amphotericin B and Flucytosine for 8 weeks.

Occult bacteraemia in cardiac implantable electronic device patients: a review of diagnostic workflow and mandatory therapy

: Cardiac implantable electronic device (CIED) implantation has greatly increased, with an associated exponential increase in CIED infections (CDIs). Cardiac device related infective endocarditis (CDRIE) has high morbidity and mortality: approximately 10-21%. Therefore, a prompt diagnosis and radical treatment of CDRIE are needed; transvenous lead extraction (TLE) is the mainstay for the complete healing, even if associated with wide logistic problems, high therapeutic costs and high mortality risk for patients. Some criticisms about the value of Duke criteria and their limitations for the diagnosis of CDRIE are known. The significance of classic laboratory data, transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE), considered in the Duke score, are reviewed and critically discussed in this article, with regard to the specific field of the diagnosis of CDI. The need for new techniques for achieving the diagnostic reliability has been well perceived by physicians, and additional techniques have been introduced in the new European Society of Cardiology (ESC) and British Heart Rhythm Society (BHRS) guidelines on infective endocarditis. These suggested techniques, such as 18-Fluorodeoxyglucose PET/computed tomography (FDG-PET/CT), white blood cell PET (WBC PET) and lung multislice CT (MSCT), are also discussed in the study. This short review is intended as an extensive summary of the diagnostic workflow in cases of CDI and will be useful for readers who want to know more about this issue.

Infection Management

Cardiovascular implantable electronic devices (CIEDs) and the indications for their use have significantly risen over the past decades to include patients who are older with more medical comorbidities. Predictably, the rates of CIED infection have increased substantially. CIED infection is associated with high morbidity, mortality, and financial costs. This article discusses the appropriate management of CIED infections, which is imperative to limit the problems associated with infection.

Cardiovascular Implantable Electronic Device Infections

Infections associated with cardiac implantable electronic devices are increasing and are associated with significant morbidity and mortality. This article reviews the epidemiology, microbiology, and risk factors for acquisition of these infections. The complex diagnostic and management strategies associated with these serious infections are reviewed with an emphasis on recent updates and advances, as well as existing controversies. Additionally, the latest in preventative strategies are reviewed.

Autonomic dysfunction in the neurological intensive care unit

Autonomic dysfunction is common in neuro-critical care patients and may compromise the function of various organs. Among the many diseases causing or being associated with autonomic dysfunction are traumatic brain injury, cerebrovascular diseases, epilepsy, Guillain-Barré syndrome (GBS), alcohol withdrawal syndrome, botulism and tetanus, among many others. Autonomic dysfunction may afflict various organs and may involve hyper- or hypo-activity of the sympathetic or parasympathetic system. In this short overview, we address only a small number of neuro-intensive care diseases with autonomic dysfunction. In GBS, autonomic dysfunction is frequent and may account for increased mortality rates; rapid changes between sympathetic and parasympathetic hypo- or hyper-activity may cause life-threatening cardiovascular complications. Paroxysmal sympathetic hyperactivity occurs after brain injury, hypoxia and cerebrovascular and other events, causes paroxysmal tachycardia, hypertension, tachypnoea and hyperthermia and is associated with a poorer prognosis and prolonged intensive care treatment. Other, at times life-threatening autonomic complications with exaggerated sympathetic activity and compromised baroreflex sensitivity arise during the alcohol withdrawal syndrome triggered by abrupt cessation of alcohol consumption. Botulism and tetanus are examples of life-threatening autonomic dysfunction caused by bacterial neurotoxins. Common neurological diseases, such as epilepsy, stroke or subarachnoid haemorrhage, are also associated with autonomic dysfunction that can on occasion cause critical deterioration of disease severity and prognosis.

Percutaneous Lead Extraction in Infection of Cardiac Implantable Electronic Devices: a Systematic Review

INTRODUCTION

In the last two decades, the increased number of implants of cardiac implantable electronic devices has been accompanied by an increase in complications, especially infection. Current recommendations for the appropriate treatment of cardiac implantable electronic devices-related infections consist of prolonged antibiotic therapy associated with complete device extraction. The purpose of this study was to analyze the importance of percutaneous extraction in the treatment of these devices infections.

METHODS

A systematic review search was performed in the PubMed, BVS, Cochrane CENTRAL, CAPES, SciELO and ScienceDirect databases. A total of 1,717 studies were identified and subsequently selected according to the eligibility criteria defined by relevance tests by two authors working independently.

RESULTS

Sixteen studies, describing a total of 3,354 patients, were selected. Percutaneous extraction was performed in 3,081 patients. The average success rate for the complete percutaneous removal of infected devices was 92.4%. Regarding the procedure, the incidence of major complications was 2.9%, and the incidence of minor complications was 8.4%. The average in-hospital mortality of the patients was 5.4%, and the mortality related to the procedure ranged from 0.4 to 3.6%. The mean mortality was 20% after 6 months and 14% after a one-year follow-up.

CONCLUSION

Percutaneous extraction is the main technique for the removal of infected cardiac implantable electronic devices, and it presents low rates of complications and mortality related to the procedure.

Is There Always a Need for Permanent Pacemaker Replacement After Device Infection? A Tale of Two Patients

There has been an increase in number of cardiac implantable electronic devices (CIEDs) implantation and with this we have witnessed increased rates of CIED infection mainly in elderly population. It is important to assess conditions that may not reliably improve with cardiac pacing or those who lack adequate beneficial effect from permanent pacing before contemplating implantation or reimplantation of these devices. Sometimes, the initial cardiac pathology may revert obviating the need for reimplantation as in the two cases that we have discussed below. This reduces the chance of further infection of CIED, and decreases mortality and morbidity due to recurrent CIED infection and decreases cost of care.

Tricuspid valve surgery in implantable cardiac electronic device-related endocarditis: Repair or replace?

Background

The aim of this study was to investigate lead endocarditis-related tricuspid valve regurgitation, to identify underlying causes, and to report our surgical approaches to tricuspid valve endocarditis.

Methods

Between March 2010 and August 2016, medical records of a total of 43 patients (23 males, 20 females; mean age: 63.2±13.6 years; range 48 to 72 years) who underwent tricuspid valve surgery for severe tricuspid regurgitation caused by lead endocarditis, which was previously placed as an implantable cardiac electronic device were reviewed. We removed all systems including infected leads and generators, revised infected wounds and tissues, performed tricuspid valve surgery for lead endocarditis, and applied long-term intravenous antibiotic regimen for the culprit agent, as confirmed by the culture.

Results

Of 43 patients, 18 underwent tricuspid valve repair and 25 underwent tricuspid valve replacement for lead endocarditisrelated severe tricuspid valve regurgitation. During followup (range, 2 to 62 months), two patients required temporary mechanical support due to postoperative acute right heart failure, while eight patients died due to sepsis (n=6; 14%) and stroke (n=2; 4.6%) in the early postoperative period. The remaining patients showed significant improvement in signs and symptoms of heart failure.

Conclusion

Our study results suggest that incompetent experience and inaccurate decision for valve repair may result in delayed valve replacement and prolonged operation time.

Right-sided infective endocarditis in cardiac device carriers: Clinical profile and prognosis

BACKGROUND AND OBJECTIVES

Due to the widespread indications for device implants and the population aging, right-sided infective endocarditis (RSIE) epidemiology has dramatically changed, being nowadays, cardiac device carriers the main affected group. The aim of this work is to describe the epidemiology, clinical profile and outcomes of RSIE in cardiac device carriers.

PATIENTS AND METHODS

We included definitive infective endocarditis episodes consecutively diagnosed in 3 tertiary centers from March 1995 to September 2014. A retrospective analysis of 85 variables, one-year follow up and univariate analysis of in-hospital mortality was conducted.

RESULTS

Among 1,182 episodes, 100 cardiac device carriers presented with RSIE (8.5%). Mean age±SD was 67±14 years. Staphylococcus spp. were the main causative microorganisms (coagulase-negative 44%, aureus 31%) and 37% were methicillin-resistant. Cardiac devices were removed in 95% of patients. In-hospital mortality was 8% and one-year mortality was 4%. Univariate analysis demonstrated that renal failure at admission (OR 6.2; 95% CI 1.3-30.3), septic shock (OR 8.9; 95% CI 1.7-47.9) and persistent infection during clinical course (OR 19.4; 95% CI 3-125.7) increase in-hospital mortality while device removal is a protective factor (OR 0.08; 95% CI 0.02-0.39).

CONCLUSIONS

RSIE have low in-hospital and one-year mortality. Coagulase-negative Staphylococci is responsible of almost half of the episodes and methicillin-resistant incidence is high. Device removal is mandatory since it decreases in-hospital mortality.

Echocardiography in Infective Endocarditis: State of the Art

PURPOSE OF REVIEW

In this review, we examine the central role of echocardiography in the diagnosis, prognosis, and management of infective endocarditis (IE).

RECENT FINDINGS

2D transthoracic echocardiography (TTE) and transesophageal echocardiography TEE have complementary roles and are unequivocally the mainstay of diagnostic imaging in IE. The advent of 3D and multiplanar imaging have greatly enhanced the ability of the imager to evaluate cardiac structure and function. Technologic advances in 3D imaging allow for the reconstruction of realistic anatomic images that in turn have positively impacted IE-related surgical planning and intervention. CT and metabolic imaging appear to be emerging as promising ancillary diagnostic tools that could be deployed in select scenarios to circumvent some of the limitations of echocardiography. Our review summarizes the indispensable and central role of various echocardiographic modalities in the management of infective endocarditis. The complementary role of 2D TTE and TEE are discussed and areas where 3D TEE offers incremental value highlighted. An algorithm summarizing a contemporary approach to the workup of endocarditis is provided and major societal guidelines for timing of surgery are reviewed.

Right-Sided Infective Endocarditis and Pulmonary Infiltrates: An Update

Sixty years after its initial description, right-sided infective endocarditis (RSIE) still poses a challenge to all medical practitioners. Epidemiological data reveal a rising incidence attributable to the global surge in the number of intravenous drug users and the increased use of central vascular catheters and implantable cardiac devices. RSIE differs from left-sided infective endocarditis in more than just the location of the involved cardiac valve. They have different clinical presentations, diagnostic findings, and prognoses; hence, they require different management strategies. Cardiac murmurs and systemic emboli are usually absent in RSIE, whereas pulmonary embolism and its related complications dominate the clinical picture. Diagnostic delay of RSIE is secondary to the similarity in its initial presentation to other entities. Complications may ensue as a result of this delay. Diagnosis can be initially confirmed by using transthoracic echocardiography, except in patients with implanted cardioverter defibrillator, where a transesophageal echocardiogram is necessary. Various factors may increase mortality and morbidity in RSIE such as tricuspid valve vegetation size, fungal etiology, and low CD4 cell count in HIV patients. Oxacillin and vancomycin had been the traditionally used agents for the treatment of methicillin-susceptible and methicillin-resistant Staphylococcus aureus, respectively. More recently, daptomycin has shown promising results, which has led to its Food and Drug Administration (FDA) approval for the treatment of S. aureus bacteremia and associated RSIE. The aim of this article is to provide a comprehensive update on RSIE including epidemiology, pathogenesis, microbiology, diagnosis, management, and prognosis.

Hybrid Minimally Invasive Approach for Transvenous Lead Extraction: A Feasible Technique in High-Risk Patients

INTRODUCTION

Despite the overall safety, transvenous lead extraction (TLE) remains a challenging procedure with inherent risks, where surgery can still be required in elective cases. In this study, we report our experience with a minimally invasive "hybrid" approach, defined as a procedure performed by an electrophysiologist with the support of a cardiac surgeon in the same operative session.

METHODS AND RESULTS

We reported 12 cases of planned hybrid lead extraction; minithoracotomy and thoracoscopy were performed on 10 (83%) and 2 (17%) patients, respectively. A total of 25 leads out of 27 (median lead age 19 years) were successfully extracted with laser, mechanical or combined transvenous sheath. In 3 patients, the direct monitoring of vascular and myocardial integrity allowed for prompt treatment of potential vascular injury during the lead extraction maneuvers. Mean in-hospital stay was 4 ± 2 days. There were no major intraoperative complications and no deaths occurred after 30 days' follow-up.

CONCLUSION

The hybrid approach, with minithoracotomy or thoracoscopy, is feasible and it might increase the safety in the most challenging TLE procedures: the minimally invasive surgical intervention allows for continuous monitoring of the critical cardiac structures and prompt treatment of potential complications.

Management of bacteremia in patients living with cardiovascular implantable electronic devices

Cardiovascular implantable electronic devices (CIEDs) have become a critical component in management of patients with cardiac rhythm disturbances, heart failure, and prevention of sudden cardiac death. However, infection remains a major complication of CIED implantation and is associated with significant morbidity and mortality for device recipients. Early-onset CIED infections frequently originate from the generator pocket, secondary to device or pocket contamination at the time of implantation, and may progress to involve device leads or cardiac valves. However, hematogenous seeding of the device leads from a remote source of bacteremia is not infrequent in patients with late-onset CIED infections. Whereas CIED pocket infection can be diagnosed in the majority of cases based on physical findings at the pulse generator site, device lead infection may only manifest with fever and positive blood cultures. However, not every patient with a CIED and positive blood cultures has underlying CIED lead infection. Consequently, management of bacteremia in a CIED recipient without local signs of infection presents a significant challenge. The risk of underlying CIED lead infection in patients presenting with bacteremia depends on several factors, including the type of microorganism isolated in blood cultures, duration and source of bacteremia, type of CIED, and number of device-related procedures. These risk factors must be considered when making decisions regarding the need for further diagnostic imaging and whether to retain or remove the device. In this article, we review the published data regarding risk of CIED infection in patients presenting with bacteremia and propose an algorithm for appropriate evaluation and management.

Lead Extraction for Treatment of Cardiac Device Infection: A 20-Year Single Centre Experience

BACKGROUND

Infection is one of the most feared complications of cardiac implantable electronic devices. We report microbiology, antimicrobial therapy and infection recurrence in patients with cardiac device infection (CDI) treated with transvenous lead extraction (TLE) at a single centre over a 20-year period.

METHODS

We identified a cohort of consecutive patients undergoing TLE for CDI by a single operator at a single high volume centre. Retrospective analysis of patient characteristics, microbiology, outcomes and infection recurrence was performed.

RESULTS

Between May 1992 to March 2012, 348 patients underwent extraction due to localised or systemic infection. Seven hundred and twenty leads were extracted from these patients. The mean follow-up was 5.5+/-4.9 years. Staphylococcal species accounted for 81% of CDI. A difference is seen in infection onset for device revision compared with initial implants [median 10 months vs 24 months, P=0.0001]. Duration of antibiotics therapy depended on the nature of the CDI (21 days post TLE for systemic vs. 10 days for localised infection, P < 0.0001). There was comparable mortality in the 37 (11.2%) patients who did not have a replacement device compared with a replacement (30% vs 29%, P=0.9). Retained lead fragments are a risk factor for CDI recurrence (20.8% recurrence in retained fragments vs 4.3% in complete removal, P=0.006).

CONCLUSION

Cardiac device infection can be successfully treated with a combination of TLE and antibiotic therapy. Device therapy can be safely withdrawn in some patients. Retained lead fragments are a risk factor for recurrent CDI following extraction.

Perioperative management for the prevention of bacterial infection in cardiac implantable electronic device placement

Cardiac implantable electronic devices (CIEDs) have become important in the treatment of cardiac disease and placement rates increased significantly in the last decade. However, despite the use of appropriate antimicrobial prophylaxis, CIED infection rates are increasing disproportionately to the implantation rate. CIED infection often requires explantation of all hardware, and at times results in death. Surgical site infection (SSI) is the most common cause of CIED infection as a pocket infection. The best method of combating CIED infection is prevention. Prevention of CIED infections comprises three phases: before, during, and after device implantation. The most critical factors in the prevention of SSIs are detailed operative techniques including the practice of proper technique by the surgeon and surgical team.

Cardiac Implantable Electronic Device Infection in Patients at Risk

The incidence of infection following implantation of cardiac implantable electronic devices (CIEDs) is increasing at a faster rate than that of device implantation. Patients with a CIED infection usually require hospitalisation and complete device and lead removal. A significant proportion die from their infection. Transvenous lead extraction (TLE) is associated with rare but serious complications including major vascular injury or cardiac perforation. Operator experience and advances in lead extraction methods, including laser technology and rotational sheaths, have resulted in procedures having a low risk of complication and mortality. Strategies for preventing CIED infections include intravenous antibiotics and aseptic surgical techniques. An additional method to reduce CIED infection may be the use of antibacterial TYRX™ envelope. Data from non-randomised cohort studies have indicated that antibacterial envelope use can reduce the incidence of CIED infection by more than 80 % in high-risk patients and a randomised clinical trial is ongoing.

Malplacement of a Pacemaker Lead — A Rare Cause for Aortic Valve Endocarditis

Infective endocarditis of native valves following pacemaker implantation is rare but can be associated with serious complications, approaching a mortality of up to 25%. 1 Recent publications report a frequency of pacemaker related endocarditis between 0.5 and 7%. 2 Due to anatomical reasons the tricuspid valve is mostly affected in these patients, with involvement of the left heart valves usually secondary. We report an incidence of native aortic valve endocarditis due to a misplaced pacemaker lead into the left heart.

Infection and readmission rate of cardiac implantable electronic device insertions: An observational single center study

BACKGROUND

Infection is one of the most serious complications following surgical placement of cardiac implantable electronic devices (CIEDs). Infection prevention efforts are necessary in reducing CIED infectious outcomes. These devices, however, are commonly inserted in higher risk patients, which may explain the ongoing risk of surgical site infection (SSI) in this population. The rates of CIED infection and utilization vary widely in the literature. The definitions of infection may also vary between clinical definitions and the National Healthcare Safety Network (NHSN) criteria.

METHODS

The primary objective of this study was to review patient data to identify risk factors for infection and readmission after CIED placement at an academic medical center. The secondary objectives were to compare the rates of SSI identified by NHSN criteria compared to that obtained by applying clinical infection definitions.

RESULTS

The overall rate of infection (SSI) was 1.9%, which was identical in both the clinical definition and NHSN reported data. The 30 day readmission rate and the 90 day readmission rate were 12.7% and 25.6% respectively with the most readmissions related to the patients' underlying medical conditions. A lower ejection fraction (EF) was identified as an independent risk factor for readmission, inpatient procedures, smoking and device infection were also significantly associated with readmission after CIED insertion.

Characteristics of cardiac device infections in the Isala Hospital; a large volume tertiary care cardiology centre

AIMS

To determine the frequency, characteristics and risk factors of cardiac device infections in the Isala Hospital.

METHODS

We retrospectively studied all patients who underwent cardiac device procedures performed in the cardiac catheterisation lab and the operating room from 2010 to 2012. All patients who developed a cardiac device infection were reviewed for its characteristics.

RESULTS

31/2026 patients developed a cardiac device infection (1.5 %). One (3.2 %) patient died within 30 days of hospitalisation. Device infection rates for procedures in the catheterisation lab and operating room were similar (p = 0.60). Positive cultures were present in 27/31 (87 %) cases. These consisted predominantly of micro-organisms that are part of the skin flora (84 %). The mean time between device procedure and infection was 14 ± 21 months (range 0-79). Cardiac device infection was significantly associated with device revision, (65 % were revisions in patients with device infection vs. 30 % revisions in patients without device infection, p = 0.011) and placement of a left ventricular lead in pacemaker implantations (59 % of patients with vs. 51 % of patients without device infection, p < 0.001).

CONCLUSION

The frequency of cardiac device infection was 1.5 % with a mortality of 3.2 % within 30 days, which is lower compared with other registries. Cardiac device infections were associated with device revisions and placement of left ventricular leads in pacemaker implantations.

The diagnostic ability of echocardiography for infective endocarditis and its associated complications

Echocardiography, transthoracic and transoesophageal, plays a key role in the diagnosis and prognosis assessment of patients with infective endocarditis. It constitutes a major Duke criterion and is pivotal in treatment guiding. Seven echocardiographic findings are major criteria in the diagnosis of infective endocarditis (IE) (vegetation, abscess, pseudoaneurysm, fistulae, new dehiscence of a prosthetic valve, perforation and valve aneurysm). Echocardiography must be performed as soon as endocarditis is suspected. Transoesophageal echocardiography should be done in most cases of left-sided endocarditis to better define the anatomic lesions and to rule out local complications. Transoesophageal echocardiography is not necessary in isolated right-sided native valve IE with good quality transthoracic examination and unequivocal echocardiographic findings. Echocardiography is a very useful tool to assess the prognosis of patients with IE at any time during the course of the disease. Echocardiographic predictors of poor outcome include presence of periannular complications, prosthetic dysfunction, low left ventricular ejection fraction, pulmonary hypertension and very large vegetations.