Intracardiac echocardiography in the detection of pacemaker lead endocarditis

Utility of Intracardiac Echocardiography for Infective Endocarditis and Cardiovascular Device-Related Endocarditis: A Contemporary Systematic Review

The diagnosis of infective endocarditis (IE) can pose a significant challenge, particularly in cases of prosthetic valve endocarditis (PVE) or cardiac device-related endocarditis (CDIE) (1). While echocardiography remains a crucial diagnostic tool for identifying IE, including PVE and CDIE, there are certain circumstances where transesophageal echocardiography (TEE) may not be conclusive or practically feasible (2). Recently, intracardiac echocardiography (ICE) has emerged as a promising alternative for diagnosing IE and evaluating intracardiac infections, especially in cases where transthoracic echocardiography (TTE) has not been revealing, and TEE has been contraindicated. Furthermore, ICE has been found to be useful in guiding transvenous lead extractions in infected implantable cardiac devices (3). This systematic review aims to comprehensively explore the various applications of ICE in the diagnosis of IE and assess its efficacy in comparison to traditional diagnostic methods.

The role of transesophageal echocardiography in predicting technical problems and complications of transvenous lead extractions procedures

Background

Transesophageal echocardiography (TEE) is a useful tool in preoperative evaluation of patients undergoing transvenous lead extraction (TLE).

Hypothesis

Echocardiographic phenomena may determine the difficulty and safety of the procedure.

Methods

Data from 936 transesophageal examinations (TEE) performed at a high volume center in patients awaiting TLE from 2015 to 2019 were assessed.

Results

TEE revealed a total of 1156 phenomena associated with the implanted leads in 697 (64.85%) patients, including: asymptomatic masses on endocardial leads (AMEL) (58.65%), vegetations (12,73%), fibrous tissue binding the lead to the vein or heart wall (33.76%), lead‐to‐lead binding sites (18.38%), excess lead loops (19.34%), intramural penetration of the lead tip (16.13%) and lead‐dependent tricuspid dysfunction (LDTD) (6.41%). Risk factors for technical difficulties during TLE in multivariate analysis were: fibrous tissue binding the lead to atrial wall (OR = 1.738; p < 0.05), to right ventricular wall (OR = 2.167; p < 0.001), lead‐to‐lead binding sites (OR = 1.628; p < 0.01) and excess lead loops (OR = 1.488; p < 0.05). Lead‐to‐lead binding sites increased probability of major complications (OR = 3.034; p < 0.05). Presence of fibrous tissue binding the lead to the superior vena cava (OR = 0.296; p < 0.05), right atrial wall (OR = 323; p < 0.05) and right ventricular wall (OR = 0.297; p < 0.05) reduced the probability of complete procedural success, whereas fibrous tissue binding the lead to the tricuspid apparatus decreased the probability of clinical success (OR = 0.307; p < 0.05).

Conclusions

Careful preoperative TEE evaluation of the consequences of extended lead implant duration (enhanced fibrotic response) increases the probability of predicting the level of difficulty of TLE procedures, their efficacy and risk of major complications.

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.

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.

Usefulness of intracardiac echocardiography for the diagnosis of cardiovascular implantable electronic device-related endocarditis

OBJECTIVES

The goal of this study was to compare transesophageal echocardiography (TEE) and intracardiac echocardiography (ICE) for the diagnosis of cardiac device-related endocarditis (CDI).

BACKGROUND

The diagnosis of infective endocarditis (IE) was established by using the modified Duke criteria based mainly on echocardiography and blood culture results. No previous studies have compared ICE with TEE for the diagnosis of IE.

METHODS

We prospectively enrolled 162 patients (age 72 ± 11 years; 125 male) who underwent transvenous lead extraction: 152 with CDI and 10 with lead malfunction (control group). Using the modified Duke criteria, we divided the patients with infection into 3 groups: 44 with a "definite" diagnosis of IE (group 1), 52 with a "possible" diagnosis of IE (group 2), and 56 with a "rejected" diagnosis of IE (group 3). TEE and ICE were performed before the procedure.

RESULTS

In group 1, ICE identified intracardiac masses (ICM) in all 44 patients; TEE identified ICM in 32 patients (73%). In group 2, 6 patients (11%) had ICE and TEE both positive for ICM, 8 patients (15%) had a negative TEE but a positive ICE, and 38 patients (73%) had ICE and TEE both negative. In group 3, 2 patients (3%) had ICM both at ICE and TEE, 1 patient (2%) had an ICM at ICE and a negative TEE, and 53 patients (95%) had no ICM at ICE and TEE. ICE and TEE were both negative in the control group.

CONCLUSIONS

ICE represents a useful technique for the diagnosis of ICM, thus providing improved imaging of right-sided leads and increasing the diagnostic yield compared with TEE.

Update on echocardiography in the management of infective endocarditis

Echocardiography is the major imaging modality used for the diagnosis of infective endocarditis (IE). It is also useful in detecting the complications of IE which often necessitate surgical intervention and strongly influence patient outcomes. Transesophageal echocardiography (TEE), with proven superiority over transthoracic echocardiography (TTE) for the detection of vegetations and complications such as abscess, should be performed in the vast majority of cases especially when TTE image quality is poor or implanted devices are present. Three-dimensional (3D) TEE provides enhanced display of anatomic-spatial relationships allowing more precise delineation of complex pathology, particularly of the mitral valve and annulus. Importantly, echocardiographic findings can be non-specific and should always be interpreted in the context of the pre-test probability of IE based on careful clinical assessment. IE remains a challenging disease associated with variable clinical presentations, and high mortality. Whenever IE is suspected, echocardiography should be utilized early for both diagnosis and detection of complications.

Intracardiac echocardiography: clinical utility and application

Intracardiac echocardiography (ICE) broadens the spectrum of available echocardiographic techniques and provides the operator direct visualization of cardiac structures in real time. ICE has clear advantages over fluoroscopy, transthoracic echocardiography, and transesophageal echocardiography as the imaging modality of choice in the cardiac catheterization and electrophysiological laboratories. With the development of steerable phased array catheters with low frequency and Doppler qualities, there is marked improvement in visualization of left-sided structures from the right heart. Appropriate utilization of ICE is likely to maximize safety and efficacy of complex interventional procedures and may improve patient outcomes. Future advances in ICE imaging will further improve the ease of device guidance and, in combination with new imaging modalities, could dramatically improve other applications of echocardiography which may result in improved patient outcomes. This review describes the technical evolution of ICE, the use of ICE in guiding percutaneous interventional procedures and possible future applications of ICE in the ever-growing field of interventional cardiology.

Recommendations for the practice of echocardiography in infective endocarditis

Echocardiography plays a key role in the assessment of infective endocarditis (IE). It is useful for the diagnosis of endocarditis, the assessment of the severity of the disease, the prediction of short- and long-term prognosis, the prediction of embolic events, and the follow-up of patients under specific antibiotic therapy. Echocardiography is also useful for the diagnosis and management of the complications of IE, helping the physician in decision-making, particularly when a surgical therapy is considered. Finally, intraoperative echocardiography must be performed in IE to help the surgeon in the assessment and management of patients with IE during surgery. The current 'recommendations for the practice of echocardiography in infective endocarditis' aims to provide both an updated summary concerning the value and limitations of echocardiography in IE, and clear and simple recommendations for the optimal use of both transthoracic and transoesophageal echocardiography in IE.

Intracardiac echocardiography in patients with pacing and defibrillating leads: a feasibility study

BACKGROUND

Lead extraction, an important and necessary component of treatment for many common device and lead-related complications, is a procedure that can provoke much anxiety in even the most experienced operators given the potentially serious complications. The principal impediment to lead extraction is the body's response to an intravascular foreign body with matrix intravascular neoformation, which causes the lead to adhere to the endocardium or vascular structure, increasing the risk of vascular or myocardial damage with lead removal. Fluoroscopic visualization, the commonly visualization used tool, has several limits in terms of anatomical structures visualization. The aim of this study was to assess the safety and feasibility of intracardiac echocardiography (ICE) in patients undergoing pacing and defibrillating leads before and during a transvenous device removal, and its potential role in detecting intracardiac leads and areas of fibrous adherence.

METHODS

ICE interrogation was performed in 25 consecutive patients with pacing and defibrillating implantable cardioverter defibrillators (ICD) leads before and during device removal.

RESULTS

A programmed ICE analysis was completed in 23 out of 25 patients with excellent resolution, providing a "qualitative-quantitative" information on anatomical structures, cardiac leads, and related areas of fibrous adherence. No ICE-related complications occurred.

CONCLUSIONS

ICE evaluation is safe and feasible in patients with pacing and defibrillating leads before and during transvenous lead removal, offering an excellent visualization of cardiac leads and related areas of adherence. ICE can assist pacing and ICD lead removal and could improve procedure efficacy and safety.

Permanent transvenous pacemaker infections: An analysis of 59 cases

BACKGROUND

Pacemaker infection is a severe process affecting 1-7% of implants. Pulse generator pocket infection is most common. Endocarditis in patients with pacemakers is quite rare. Clinical signs include systemic-related symptoms and severe complications in as many as 40% of cases. The aim of our study was to review our experience and to analyze the epidemiology and treatment of those patients diagnosed as having pacemaker lead endocarditis.

METHODS

A retrospective study included all patients diagnosed as having pacemaker endocarditis in our hospital from 1996 to 2002.

RESULTS

Fifty-nine patients with pacemaker-related infection were identified, including 39 (66%) with pocket infection. Fever occurred in 25 patients (42%). In 39 patients, a germ was isolated, corresponding to Staphylococcus spp. in 22 (56%). Transthoracic echocardiography demonstrated vegetations in 7 patients (12%), whereas transesophageal echocardiography disclosed abnormal appearances on the pacemaker lead in 10 patients (17%). Ten patients were treated exclusively with antibiotics, while 38 patients required the removal of all infected material. Two patients died.

CONCLUSIONS

The diagnosis of endocarditis related to pacemaker infection should be suspected in the presence of fever. High morbidity and mortality are associated with this disease. Prompt treatment, including in some cases removal of the device, is mandatory.

Challenges and implementation of radiation-force imaging with an intracardiac ultrasound transducer

Intracardiac echocardiography (ICE) has been demonstrated to be an effective imaging modality for the guidance of several cardiac procedures, including radiofrequency ablation (RFA). However, assessing lesion size during the ablation with conventional ultrasound has been limited, as the associated changes within the B-mode images often are subtle. Acoustic radiation force impulse (ARFI) imaging is a promising modality to monitor RFAs as it is capable of visualizing variations in local stiffnesses within the myocardium. We demonstrate ARFI imaging with an intracardiac probe that creates higher quality images of the developing lesion. We evaluated the performance of an ICE probe with ARFI imaging in monitoring RFAs. The intracardiac probe was used to create high contrast, high resolution ARFI images of a tissue-mimicking phantom containing stiffer spherical inclusions. The probe also was used to examine an excised segment of an ovine right ventricle with a RFA-created surface lesion. Although the lesion was not visible in conventional B-mode images, the ARFI images were able to show the boundaries between the lesion and the surrounding tissue. ARFI imaging with an intracardiac probe then was used to monitor cardiac ablations in vivo. RFAs were performed within the right atrium of an ovine heart, and B-mode and ARFI imaging with the intracardiac probe was used to monitor the developing lesions. Although there was little indication of a developing lesion within the B-mode images, the corresponding ARFI images displayed regions around the ablation site that displaced less.

Pacemaker Endocarditis: Clinical Features and Management of 60 Consecutive Cases

BACKGROUND

The incidence of endocarditis related to pacemakers is increasing, while the diagnosis and management remain difficult. The objective of this study was to evaluate the clinical features and management of endocarditis after implantation of pacemakers (PM) or cardioverter defibrillators (ICD).

METHODS

We analyzed the hospital course of 60 consecutive patients (48 men, mean age 68 +/- 12 years) admitted to our center for PM (n = 59) or ICD (n = 1) endocarditis between 1998 and 2004.

RESULTS

Fever (78%), asthenia (65%), and local symptoms (35%) were common. Positive cultures were obtained in 53 cases (Staphylococcus 89%). Sixteen patients (27%) had pulmonary embolism. Vegetations (mean size 15.2 +/- 8 mm, range 5 to 35 mm) were found in 54 cases (90%), with transthoracic echocardiography in 26 cases (43%), and transesophageal echocardiography (TEE) in 50 cases (89% of the 56 patients who had TEE). Devices were removed surgically (n = 20) or percutaneously (n = 37). In the surgical group, vegetations were larger (17.9 +/- 7 mm vs 13.2 +/- 7 mm, P = 0.01). After removal, 42 patients (70%) had a new PM. Mortality factors (6 deaths - follow up 3.4 +/- 2 years) were the number of vegetations and absence of extraction of the device (P < 0.02). Clinical features and management of the 37 patients with early onset endocarditis (within 1 year after implantation) did not differ from those with late onset.

CONCLUSIONS

PM endocarditis was essentially staphylococcal. TEE was required for the diagnosis of vegetations. Complete removal of the device is required and associated with a favorable outcome.

Intracardiac echo guided valvuloplasty of a stenotic tricuspid prosthetic valve in a patient with idiopathic hypereosinophilic syndrome

A 52-year-old male with idiopathic hypereosinophilic syndrome (HES) was transferred to our institution following the development of acute respiratory failure and shock. He had previously undergone tricuspid valve replacement with bioprosthetic valves on two occasions: the initial surgery for severe native tricuspid valve stenosis and the redo surgery for severe prosthetic valve stenosis and regurgitation. Conventional imaging assessment using transoesophageal echocardiography was suboptimal and comprehensive assessment of prosthetic valve function was aided by the use of intracardiac echocardiography (ICE). ICE provided high quality 2D imaging of the prosthesis demonstrating thrombus-like material coating the inner surfaces of the prosthetic valve stents effectively forming a tunnel-like obstruction. Unusual hemodynamics secondary to severe tricuspid stenosis were demonstrated by CW Doppler with intermittent "signal fusion" resulting from blunted respiratory variation in the markedly elevated right atrial pressure relative to right ventricular pressure. Successful balloon valvuloplasty was performed with ICE proving highly valuable in guiding balloon position as well as monitoring the efficacy of the subsequent inflations.

Role of Echocardiography in Diagnosis and Management of Endocarditis

Echocardiography plays an increasingly important role in diagnosis and management of patients with infective and noninfective endocarditis. Significant changes to diagnostic criteria for endocarditis have occurred, and there are evolving trends associated with an older population presenting with endocarditis, greater numbers of patients with prosthetic heart valves and complex congenital heart disease, and an exponential increase in the numbers of patients eligible for pacing and defibrillator implants. The diagnostic accuracy of echocardiography has been enhanced by developments such as multiplanar transesophageal probes, real-time three-dimensional echocardiography, and intracardiac echocardiography. Standard echocardiography techniques now define the need for and timing of surgical intervention in endocarditis and may help determine the duration of treatment and follow-up after diagnosis.

Pacemaker lead endocarditis caused by Achromobacter xylosoxidans

We report the case of a 35-yr-old patient who presented with high fever and chills. He had undergone a patch closure of the ventricular septal defect 18 yr before. One year later, a VVI pacemaker was implanted via the right subclavian vein because of complete heart block. Nine years after that, a new VVI pacemaker with another right ventricular electrode was inserted controlaterally and the old pacing lead was abandoned. Trans-thoracic and trans-esophageal echocardiogram identified the pacemaker lead in the right ventricle (RV) attaching hyperechoic materials and also a fluttering round hyperechoic mass with a stalk in the RV outflow tract. Cultures in blood and pus from pacemaker lead grew Achromobacter xylosoxidans. A diagnosis of pacemaker lead endocarditis due to Achromobacter xylosoxidans was made. In this regards, the best treatment is an immediate removal of the entire pacing system and antimicrobial therapy.

Role of intracardiac ultrasound in interventional electrophysiology

PURPOSE OF REVIEW

Interventional procedures in the electrophysiology and catheterization laboratory are rapidly advancing. Critical to the advancement of these procedures is accurate identification of critical anatomic landmarks and catheter position. Fluoroscopy remains the mainstay for general identification of anatomic landmarks but is inadequate for the precise imaging needed for complex procedures. Precise imaging of anatomic landmarks and catheter position is now possible during the procedure with the use of intracardiac echocardiography (ICE). This paper reviews the rapid development and utilization of ICE in interventional electrophysiology.

RECENT FINDINGS

Several recent studies show ICE as a major contribution to providing a safer, more reliable, and more cost-effective means of accomplishing the tasks performed by existing techniques. In the electrophysiology laboratory, the dependence on this new technology has been due to the rapid development of catheter-based radiofrequency ablation of the pulmonary veins for treatment of atrial fibrillation. Since the initial use of ICE in facilitating ablation of atrial fibrillation, other uses for ICE are continuously being identified.

SUMMARY

A comprehensive look is provided at the history and development of this new technology along with the most recent applications of ICE in interventional electrophysiology.