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Kim H, Kim S, Park S, Kim S, Choi Y, Kim JY, Oh YS, Kim SH. Clinical impact of capsulectomy during cardiac implantable electronic device generator replacement: a prospective randomized trial. J Interv Card Electrophysiol 2024; 67:1211-1217. [PMID: 38374300 DOI: 10.1007/s10840-024-01765-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/30/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND The avascular capsule around the generator of the cardiac implantable electronic device (CIED) could be susceptible to bacterial colonization and source of infection. Capsulectomy during CIED generator replacement may be beneficial in preventing device infection, but there is a lack of evidence. METHODS This prospective randomized trial, conducted from December 2013 to December 2019, included 195 patients divided equally into two groups. In the intervention group (n = 97), capsule removal was performed on the floor of the pocket, while it was not performed in the control group (n = 98). In both groups, swab culture was performed in the pocket. The primary outcome was the occurrence of device infection requiring pocket revision. RESULTS A total of 195 patients were included (mean age 70.2 ± 13.6 years, 55.4% women), with an average follow-up period of 54.3 ± 28.9 months. Among 182 patients undergoing microbiological cultures of pockets, 19 (10.4%) were confirmed positive, and Staphylococcus species were identified most frequently. The primary outcome occurred in 4 (2.1%), and there was no significant difference between the two groups (3.1% vs. 1.0%, p = 0.606). Hematoma has occurred in 10 patients (3.1% vs. 7.1%, p = 0.338), one of them required wound revision. In multivariable analysis, the occurrence of hematoma was the only independent risk factor associated with device infection (HR 13.6, 95% CI 1.02-181.15, p = 0.048). CONCLUSIONS In this long-term prospective study, capsulectomy during the replacement of the generator did not reduce the incidence of device infection. There was no association between bacterial colonization in the capsule around the generator and CIED infection.
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Affiliation(s)
- Hwajung Kim
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Division of Cardiology, Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Soohyun Kim
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Soyoon Park
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sunhwa Kim
- Division of Cardiology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Republic of Korea
| | - Young Choi
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ju Youn Kim
- Division of Cardiology, Department of Internal Medicine, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yong-Seog Oh
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung-Hwan Kim
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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Aydin A, Golian M, Klein A, Redpath C, Davis DR, Ramirez DF, Nair GM, Green M, Sadek M, Nery PB, Hansom SP, Corrales-Medina V, Wells GA, Birnie DH. Do barrier dressings reduce cardiac implantable device infection: Protocol for a randomized controlled trial (BARRIER-PROTECT). Heliyon 2023; 9:e22229. [PMID: 38046145 PMCID: PMC10686845 DOI: 10.1016/j.heliyon.2023.e22229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 11/03/2023] [Accepted: 11/07/2023] [Indexed: 12/05/2023] Open
Abstract
Background Cardiac implantable electronic device (CIED) procedures can be associated with serious complications, including infection with significant mortality and morbidity, necessitating removal of the device and prolonged hospitalization. One potential pathophysiological mechanism is pocket contamination at the time of device implantation. Therefore, steps taken to prevent contamination at this stage can potentially reduce CIED infections.The barrier dressing, an adhesive material applied to the skin, has the potential to reduce the colonization of the surgical site with host flora that can predispose to infection. There are a limited number of randomized prospective studies on barrier dressing use during various surgeries, but it has never been systematically studied in CIED implantation. Objectives Do Barrier Dressings Reduce Cardiac Implantable Device Infection? (BARRIER-PROTECT trial; NCT04591366) is a single-centre, prospective, double-armed, single-blinded, randomized controlled trial designed to evaluate the use of an intra-operative adhesive barrier dressing to reduce the risk of end-of-procedure pocket swab positivity. We hypothesize that adhesive draping during implant procedures will reduce the risk of contamination from the skin flora. Also, we aim to investigate if the end-of-procedure pocket swab culture positivity can be used as a potential surrogate marker of CIED infection. Methods and Design Patients undergoing a second or later procedure on the same device pocket (pulse generator change, lead/pocket revision or upgrade) will be enrolled. Eligible and consenting patients will be equally randomized to the use of barrier dressing or not using an automated web-based system. Patients, but not the operator, will be blinded to the arm. The person performing the pocket swabs will also be blinded. The primary endpoint is the end-of-procedure pocket swab culture positivity. The main secondary endpoint is the CIED infection rate. Discussion This is the first randomized controlled trial to assess the effectiveness of using a barrier adhesive draping on reducing the end-of-procedure pocket swab culture positivity. In this study, we are exploring a low-cost intervention that may significantly reduce CIED infection. Also, having a valid surrogate marker for CIED infection at the time of implant will facilitate design of future clinical trials.
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Affiliation(s)
- Alper Aydin
- Division of Cardiology, University of Ottawa Heart Institute, Canada
| | - Mehrdad Golian
- Division of Cardiology, University of Ottawa Heart Institute, Canada
| | - Andres Klein
- Division of Cardiology, University of Ottawa Heart Institute, Canada
| | - Calum Redpath
- Division of Cardiology, University of Ottawa Heart Institute, Canada
| | - Darryl R. Davis
- Division of Cardiology, University of Ottawa Heart Institute, Canada
| | - Daniel F. Ramirez
- Division of Cardiology, University of Ottawa Heart Institute, Canada
| | - Girish M. Nair
- Division of Cardiology, University of Ottawa Heart Institute, Canada
| | - Martin Green
- Division of Cardiology, University of Ottawa Heart Institute, Canada
| | - Mouhannad Sadek
- Division of Cardiology, University of Ottawa Heart Institute, Canada
| | - Pablo B. Nery
- Division of Cardiology, University of Ottawa Heart Institute, Canada
| | - Simon P. Hansom
- Division of Cardiology, University of Ottawa Heart Institute, Canada
| | - Vicente Corrales-Medina
- Division of Infectious Diseases, Department of Medicine, University of Ottawa, and The Ottawa Hospital, Canada
| | - George A. Wells
- Division of Cardiology, University of Ottawa Heart Institute, Canada
| | - David H. Birnie
- Division of Cardiology, University of Ottawa Heart Institute, Canada
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Diaz JC, Braunstein ED, Cañas F, Duque M, Marín JE, Aristizabal J, Niño CD, Bastidas O, Hoyos C, Steiger NA, Matos CD, Sauer WH, Romero JE. Chlorhexidine gluconate pocket lavage to prevent cardiac implantable electronic device infection in high-risk procedures. Heart Rhythm 2023; 20:1674-1681. [PMID: 37598986 DOI: 10.1016/j.hrthm.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/06/2023] [Accepted: 08/10/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND Infection is the most dreaded complication of cardiac implantable electronic devices (CIEDs), particularly in patients undergoing high-risk procedures (eg, generator change, device upgrade, lead/pocket revision). OBJECTIVE The purpose of this study was to describe the impact of chlorhexidine gluconate (CHG) pocket lavage in high-risk procedures. METHODS Patients from a prospective multicenter registry undergoing high-risk procedures were included. CHG lavage was performed by irrigating the generator pocket with 20 cc of 2% CHG without alcohol followed by and normal saline (NS) irrigation. Only NS irrigation was performed in the comparison group. The primary efficacy outcome was CIED-related infection at 12 months. The primary safety outcome was any CHG-associated adverse event. The secondary outcome was CIED infection during long-term follow-up. Propensity score matching (PSM) analysis was performed for the primary efficacy outcome. RESULTS A total of 1504 patients were included. At 12-month follow-up, the primary efficacy outcome occurred in 4 of 904 CHG (0.4%) and 14 of 600 NS (2.3%) subjects (log-rank P = .005). On multivariate analysis, the use of CHG irrigation was associated with a lower risk of infection at 1-year follow-up (Cox proportional hazard ratio [HR] 0.138; 95% confidence interval [CI] 0.04-0.45; P = .001). This effect persisted during long-term follow-up. PSM demonstrated a significant reduction in CIED-related infection for the CHG group (0.2% vs 2.5%; Cox proportional HR 0.08; 95% CI 0.01-0.59; P = .014). No adverse events were associated with the use of CHG. CONCLUSION CHG lavage during high-risk procedures was associated with a reduction in CIED-related infections without any adverse events reported. The benefits of CHG lavage were observed even during long-term follow up and in PSM analysis.
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Affiliation(s)
- Juan Carlos Diaz
- Cardiac Arrhythmia and Electrophysiology Service, Division of Cardiology, Clinica Las Vegas, Universidad CES Medical School, Medellin, Colombia.
| | - Eric D Braunstein
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai, Los Angeles, California
| | - Felipe Cañas
- Universidad CES School of Medicine, Medellin, Colombia
| | - Mauricio Duque
- Cardiac Electrophysiology Service, Hospital San Vicente Fundación, Rionegro, Colombia
| | - Jorge Eduardo Marín
- Cardiac Arrhythmia and Electrophysiology Service, Division of Cardiology, Department of Medicine, Clinica Las Americas, Medellin, Colombia
| | - Julian Aristizabal
- Cardiac Arrhythmia and Electrophysiology Service, Division of Cardiology, Department of Medicine, Clinica Las Americas, Medellin, Colombia
| | - Cesar Daniel Niño
- Cardiac Arrhythmia and Electrophysiology Service, Hospital Pablo Tobon, Medellin, Colombia
| | - Oriana Bastidas
- Cardiac Arrhythmia and Electrophysiology Service, Division of Cardiology, Clinica Las Vegas, Universidad CES Medical School, Medellin, Colombia
| | - Carolina Hoyos
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nathaniel A Steiger
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Carlos D Matos
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - William H Sauer
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jorge E Romero
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Ziacchi M, Biffi M, Iacopino S, di Silvestro M, Marchese P, Miscio F, Caccavo VP, Zanotto G, Tomasi L, Dello Russo A, Donazzan L, Boriani G. REducing INFectiOns thRough Cardiac device Envelope: insight from real world data. The REINFORCE project. Europace 2023; 25:euad224. [PMID: 37490930 PMCID: PMC10637307 DOI: 10.1093/europace/euad224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 06/18/2023] [Indexed: 07/27/2023] Open
Abstract
AIMS Infections resulting from cardiac implantable electronic device (CIED) implantation are severely impacting on patients' and on health care systems. The use of TYRXTM absorbable antibiotic-eluting envelope has proven to decrease major CIED infections within 12 months of CIED surgery. The aim is to evaluate the impact of the envelope use on infection-related clinical events in a real-world contemporary patient population. METHODS AND RESULTS Data on patients undergoing CIED surgery were collected prospectively by participating centers of the One Hospital ClinicalService project. Patients were divided into two groups according to whether TYRXTM absorbable antibiotic-eluting envelope was used or not. Out of 1819 patients, 872 (47.9%) were implanted with an absorbable antibiotic-eluting envelope and included in the Envelope group and 947 (52.1%) patients who did not receive an envelope were included in the Control group. Compared to control, patients in the Envelope group had higher thrombo-embolic or hemorrhagic risk, higher BMI, lower LVEF and more comorbidities. During a mean follow-up of 1.4 years, the incidence of infection-related events was significantly higher in the control compared to the Envelope group (2.4% vs. 0.8%, P = 0.007). The five-year cumulative incidence of infection-related events was 8.1% in the control and 2.1% in the Envelope group (HR: 0.34, 95%CI: 0.14-0.80, P = 0.010). CONCLUSION In our analysis, the use of an absorbable antibiotic-eluting envelope in the general CIED population was associated with a lower risk of systemic and pocket infection.
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Affiliation(s)
- Matteo Ziacchi
- Institute of Cardiology, IRCCS Azienda Ospedaliero Universitaria di Bologna, Via Massarenti 9, 40125 Bologna, Italy
| | - Mauro Biffi
- Institute of Cardiology, IRCCS Azienda Ospedaliero Universitaria di Bologna, Via Massarenti 9, 40125 Bologna, Italy
| | | | | | | | | | | | | | | | | | - Luca Donazzan
- Cardiology Department, Ospedale San Maurizio, Bolzano, Italy
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
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Srivastava A, Nayak HM. Rehabilitation of an existing device implant pocket using a biologic extracellular matrix envelope. HeartRhythm Case Rep 2023; 9:797-799. [PMID: 38023680 PMCID: PMC10667117 DOI: 10.1016/j.hrcr.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Affiliation(s)
- Ankur Srivastava
- Center for Arrhythmia Care, The University of Chicago Medicine, Chicago, Illinois
| | - Hemal M. Nayak
- Address reprint requests and correspondence: Dr Hemal M. Nayak, The University of Texas Health Science Center, 8300 Floyd Curl Dr, San Antonio, TX 78229.
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Borov S, Baldauf B, Henke J, Pavaci H, Perani A, Zrenner B, Dietl J, Mehilli J, Lau EW, Vonthein R, Bonnemeier H. Use of a taurolidine containing antimicrobial wash to reduce cardiac implantable electronic device infection. Europace 2023; 25:euad306. [PMID: 37831737 PMCID: PMC10616572 DOI: 10.1093/europace/euad306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/25/2023] [Indexed: 10/15/2023] Open
Abstract
AIMS TauroPace (Tauropharm, Bavaria Germany), a taurolidine solution for combating cardiac implantable electronic device (CIED) infection, was compared with a historical control of 3% hydrogen peroxide (H2O2) in a prospective observational study. METHODS AND RESULTS The device pocket was irrigated, and all hardware accessible within (leads, suture sleeves, pulse generator) was wiped with H2O2, TauroPace, or taurolidine in a galenic formulation during any invasive CIED procedure at the study centre. Only CIED procedures covered by TauroPace or H2O2 from 1 January 2017 to 28 February 2022 were included for analysis. Patients who underwent >1 procedure were censored for the last treatment group and reassigned at the next procedure. The primary endpoint was major CIED infection within 3 months. The secondary endpoints were CIED infection beyond 3 months, adverse events potentially related to the antimicrobial solutions, CIED system, procedure, and death, till the end of follow-up. TauroPace covered 654 procedures on 631 patients, and H2O2 covered 551 procedures on 532 patients. The TauroPace group had more patient risk factors for infection than the H2O2 group (P = 0.0058) but similar device and procedure-specific risk factors (P = 0.17). Cardiac implantable electronic device infection occurred in 0/654 (0%) of the TauroPace group and 6/551 (1.1%) of the H2O2 group (P = 0.0075). Death occurred in 23/654 (3.5%) of the TauroPace group and 14/551 (2.5%) of the H2O2 group (P = 0.33). Non-infection related adverse events were rarer in the TauroPace (3.8%) than the H2O2 (6.0%) group (P = 0.0802). CONCLUSION TauroPace is safe but more effective than H2O2 in reducing CIED infection. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05576194.
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Affiliation(s)
- Stefan Borov
- Department of Cardiology, Klinikum Freising, Alois-Steinecker-Straße 18, Freising 85354, Germany
- Medical Faculty, Christian-Albrechts University, Christian-Albrechts-Platz 4, Kiel 24118, Germany
| | - Benito Baldauf
- Medical Faculty, Christian-Albrechts University, Christian-Albrechts-Platz 4, Kiel 24118, Germany
- Institute of Life Science, Hochschule Bremerhaven, An der Karlstadt 8, Bremerhaven 27568, Germany
| | - Jana Henke
- Medical Faculty, Christian-Albrechts University, Christian-Albrechts-Platz 4, Kiel 24118, Germany
| | - Herribert Pavaci
- Krankenhaus Landshut Achdorf, Achdorfer Weg 3, Landshut 84036, Germany
| | - Arben Perani
- Krankenhaus Landshut Achdorf, Achdorfer Weg 3, Landshut 84036, Germany
| | - Bernhard Zrenner
- Krankenhaus Landshut Achdorf, Achdorfer Weg 3, Landshut 84036, Germany
| | - Josef Dietl
- Krankenhaus Landshut Achdorf, Achdorfer Weg 3, Landshut 84036, Germany
| | - Julinda Mehilli
- Krankenhaus Landshut Achdorf, Achdorfer Weg 3, Landshut 84036, Germany
| | - Ernest W Lau
- Department of Cardiology, Royal Victoria Hospital, Grosvenor Road, Belfast BT12 6BA, UK
| | - Reinhard Vonthein
- Institut für Medizinische Biometrie und Statistik, Universität zu Lübeck, Ratzeburger Allee 160, Lübeck 23562, Germany
| | - Hendrik Bonnemeier
- Medical Faculty, Christian-Albrechts University, Christian-Albrechts-Platz 4, Kiel 24118, Germany
- Institute of Life Science, Hochschule Bremerhaven, An der Karlstadt 8, Bremerhaven 27568, Germany
- Department of Cardiology, Helios Klinikum Cuxhaven, Altenwalder Ch 10, Cuxhaven 27474, Germany
- Department of Cardiology, Helios Klinikum Wesermarsch, Mildred-Scheel-Straße 1, Nordenham 26954, Germany
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Vonthein R, Baldauf B, Borov S, Lau EW, Giaccardi M, Cemin R, Assadian O, Chévalier P, Bode K, Bonnemeier H. The European TauroPace™ Registry. Methods Protoc 2023; 6:86. [PMID: 37736969 PMCID: PMC10514882 DOI: 10.3390/mps6050086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/08/2023] [Accepted: 09/12/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Cardiac implantable electronic device (CIED) placement comes with certain complications. CIED infection is a severe adverse event related to CIED placement. In randomised controlled trials, the preoperative intravenous administration of antibiotics and the adjunctive use of an antibiotic mesh envelope resulted in significant reduction in infections related to cardiac implantable electronic devices. The adjunctive use of taurolidine for this purpose is relatively novel and not considered in the guidelines. The required evidence may consist of a set of clinical studies. METHODS The European TauroPaceTM registry (ETPR) prospectively evaluates every consecutive invasive procedure involving any CIED with adjunct TauroPace™ use in the contributing centres. As the estimation of the infection rate needs to be defensible, only interventions registered prior to the procedure will be followed-up. The endpoint is a major cardiac implantable electronic device infection according to the novel CIED infection criteria (1). Secondary endpoints comprise all-cause mortality, complications, adverse events of all grades, and major CIED infections during all follow-up examinations. The follow-up times are three months, twelve months, and eventually 36 months, as acute, subacute, and long-term CIED infections are of interest. RESULTS As the rate of CIED infections is expected to be very low, this registry is a multicentre, international project that will run for several years. Several reports are planned. The analyses will be included in the case number calculations for future randomised controlled trials. CONCLUSIONS The ETPR will accumulate large case numbers to estimate small event rates more precisely; we intend to follow up on participants for years to reveal possible late effects.
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Affiliation(s)
- Reinhard Vonthein
- Institut für Medizinische Biometrie und Statistik, Universität zu Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Benito Baldauf
- Institute of Life Science, Hochschule Bremerhaven, An der Karlstadt 8, 27568 Bremerhaven, Germany
- Medical Faculty, Christian-Albrechts University, Christian-Albrechts-Platz 4, 24118 Kiel, Germany
| | - Stefan Borov
- Medical Faculty, Christian-Albrechts University, Christian-Albrechts-Platz 4, 24118 Kiel, Germany
- Department of Cardiology, Klinikum Freising, Alois-Steinecker-Straße 18, 85354 Freising, Germany
| | - Ernest W. Lau
- Department of Cardiology, Royal Victoria Hospital, Grosvenor Road, Belfast BT12 6BA, UK
| | - Marzia Giaccardi
- Department of Cardiology, Ospedale Santa Maria Annunziata, Ponte a Niccheri, 50012 Florence, Italy
| | - Roberto Cemin
- Department of Cardiology, Ospedale Regionale San Maurizio, Bolzano, Via Lorenz Böhler 5, 39100 Bolzano, Italy
| | - Ojan Assadian
- Regional Hospital Wiener Neustadt, Wiener Neustadt 2700, Austria
- Institute for Skin Integrity and Infection Prevention, School of Human and Health Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK
| | - Philippe Chévalier
- Department of Cardiology, Hôpital Louis Pradel, 59 Bd Pinel, 69500 Bron, France
| | - Kerstin Bode
- Department of Electropyhsiology, Herzzentrum Leipzig, Strümpellstraße 39, 04289 Leipzig, Germany
| | - Hendrik Bonnemeier
- Institute of Life Science, Hochschule Bremerhaven, An der Karlstadt 8, 27568 Bremerhaven, Germany
- Medical Faculty, Christian-Albrechts University, Christian-Albrechts-Platz 4, 24118 Kiel, Germany
- Department of Cardiology, Helios Klinikum Cuxhaven, Altenwalder Ch 10, 27474 Cuxhaven, Germany
- Department of Cardiology, Helios Klinikum Wesermarsch, Mildred-Scheel-Straße 1, 26954 Nordenham, Germany
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Milman A, Wieder-Finesod A, Zahavi G, Meitus A, Kariv S, Shafir Y, Beinart R, Rahav G, Nof E. Complicated Pocket Infection in Patients Undergoing Lead Extraction: Characteristics and Outcomes. J Clin Med 2023; 12:4397. [PMID: 37445433 DOI: 10.3390/jcm12134397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/18/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
Cardiac implantable electronic device (CIED) infection can present with pocket or systemic manifestations, both necessitating complete device removal and pathogen-directed antimicrobial therapy. Here, we aim to characterize those presenting with both pocket and systemic infection. A retrospective analysis of CIED extraction procedures included 300 patients divided into isolated pocket (n = 104, 34.7%), complicated pocket (n = 54, 18%), and systemic infection (n = 142, 47.3%) groups. The systemic and complicated pocket groups frequently presented with leukocytosis and fever > 37.8, as opposed to the isolated pocket group. Staphylococcus aureus was the most common pathogen in the systemic and complicated pocket groups (43.7% and 31.5%, respectively), while Coagulase-negative staphylococci (CONS) predominated (31.7%) in the isolated pocket group (10.6%, p < 0.001). No differences were observed in procedural success or complications rates. Kaplan-Meier survival analysis found that at three years of follow-up, the rate of all-cause mortality was significantly higher among patients with systemic infection compared to both pocket groups (p < 0.001), with the curves diverging at thirty days. In this study, we characterize a new entity of complicated pocket infection. Despite the systemic pattern of infection, their prognosis is similar to isolated pocket infection. We suggest that this special category be presented separately in future publications of CIED infections.
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Affiliation(s)
- Anat Milman
- Leviev Heart Institute, The Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan 5262000, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Anat Wieder-Finesod
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- The Infectious Diseases Unit, Sheba Medical Center, Tel-Hashomer, Ramat Gan 5262000, Israel
| | - Guy Zahavi
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Department of Anesthesiology and Intensive Care, The Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan 5262000, Israel
| | - Amit Meitus
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Saar Kariv
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Yuval Shafir
- Leviev Heart Institute, The Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan 5262000, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Roy Beinart
- Leviev Heart Institute, The Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan 5262000, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Galia Rahav
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- The Infectious Diseases Unit, Sheba Medical Center, Tel-Hashomer, Ramat Gan 5262000, Israel
| | - Eyal Nof
- Leviev Heart Institute, The Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan 5262000, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
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Rodríguez-Fernández M, López Cortés LE. Patogenia, factores de riesgo y prevención de las infecciones de dispositivos de estimulación cardiaca. CIRUGIA CARDIOVASCULAR 2023. [DOI: 10.1016/j.circv.2022.12.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
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10
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Olsen T, Jørgensen OD, Nielsen JC, Thøgersen AM, Philbert BT, Frausing MHJP, Sandgaard NCF, Johansen JB. Risk factors for cardiac implantable electronic device infections: a nationwide Danish study. Eur Heart J 2022; 43:4946-4956. [PMID: 36263789 PMCID: PMC9748591 DOI: 10.1093/eurheartj/ehac576] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 08/05/2022] [Accepted: 09/29/2022] [Indexed: 01/12/2023] Open
Abstract
AIMS Cardiac implantable electronic device (CIED) infection is a severe complication to modern management of cardiac arrhythmias. The CIED type and the type of surgery are recognized as risk factors for CIED infections, but knowledge of patient-related risk factors is scarce. This study aimed to identify lifelong patient-related risk factors for CIED infections. METHODS AND RESULTS Consecutive Danish patients undergoing a CIED implantation or reoperation between January 1996 and April 2018 were included. The cohort consisted of 84 429 patients undergoing 108 494 CIED surgeries with a combined follow-up of 458 257 CIED-years. A total of 1556 CIED explantations were classified as either pocket (n = 1022) or systemic CIED infection (n = 534). Data were cross-linked with records from the Danish National Patient Registry and the Danish National Prescription Registry. Using multiple-record and multiple-event per subject proportional hazard analysis, specific patient-related risk factors were identified but with several variations amongst the subtypes of CIED infection. CIED reoperations were associated with the highest risk of pocket CIED infection but also CIED type, young age, and prior valvular surgery [hazard ratio (HR): 1.62, 95% confidence interval (CI): 1.29-2.04]. Severe renal insufficiency/dialysis (HR: 2.40, 95% CI: 1.65-3.49), dermatitis (HR: 2.80, 95% CI: 1.92-4.05), and prior valvular surgery (HR: 2.09, 95% CI: 1.59-2.75) were associated with the highest risk of systemic CIED infections. Congestive heart failure, ischaemic heart disease, malignancy, chronic obstructive pulmonary disease, and temporary pacing were not significant at multivariate analysis. CONCLUSION Specific comorbidities and surgical procedures were associated with a higher risk of CIED infections but with variations amongst pocket and systemic CIED infection. Pocket CIED infections were associated with CIED reoperations, young age and more complex type of CIED, whereas systemic CIED infections were associated with risk factors predisposing to bacteraemia.
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Affiliation(s)
- Thomas Olsen
- Corresponding author. Tel: +45 2635 1337, Fax: +45 6541 3003,
| | - Ole Dan Jørgensen
- Department of Heart, Lung and Vascular Surgery, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Region of Southern Denmark, Denmark,Danish Pacemaker and ICD Register, Department of Cardiology, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Region of Southern Denmark, Denmark
| | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Central Denmark Region, Denmark,Danish Pacemaker and ICD Register, Department of Cardiology, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Region of Southern Denmark, Denmark
| | - Anna Margrethe Thøgersen
- Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, North Denmark Region, Denmark
| | - Berit Thornvig Philbert
- Department of Cardiology, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Capital Region of Denmark, Denmark,Danish Pacemaker and ICD Register, Department of Cardiology, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Region of Southern Denmark, Denmark
| | - Maria Hee Jung Park Frausing
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Central Denmark Region, Denmark
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11
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Phillips P, Krahn AD, Andrade JG, Chakrabarti S, Thompson CR, Harris DJ, Forman JM, Karim SS, Sterns LD, Fedoruk LM, Partlow E, Bashir J. Treatment and Prevention of Cardiovascular Implantable Electronic Device (CIED) Infections. CJC Open 2022; 4:946-958. [DOI: 10.1016/j.cjco.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/03/2022] [Indexed: 10/15/2022] Open
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12
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Polewczyk A, Jacheć W, Polewczyk M, Szczęśniak-Stańczyk D, Kutarski A. Early, Delayed and Late Cardiac Implantable Electronic Device Infections: Do the Timing of Onset and Pathogens Matter? J Clin Med 2022; 11:jcm11143929. [PMID: 35887692 PMCID: PMC9319565 DOI: 10.3390/jcm11143929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 06/27/2022] [Accepted: 06/28/2022] [Indexed: 11/09/2022] Open
Abstract
Infections involving cardiac implantable electronic devices (CIEDs) occur at different times after device-related procedures. The aim of this study was to investigate the timing of onset and factors influencing the occurrence of all types of CIED infections to identify the type of pathogen and to examine the long-term survival of patients with all types of CIED infections. We performed a post hoc analysis of the clinical data from 3344 patients who underwent transvenous lead extraction (TLE) at a single high-volume center between 2006 and 2020, including a group of 890 patients with CIED infections. The occurrence of pocket infection (PI), lead-related infective endocarditis (LRIE) and PI coexisting with LRIE (PI + LRIE) was assessed at the following time intervals: 0−12 months, 13−36 months and > 36 months since last CIED-related procedure. In the study group, there were 274 (30.79%) early infections, 266 (29.89%) delayed infections and 350 (39.32%) late infections. Pocket infection was the most common early complication (97; 39.43%), while LRIE was predominant over 36 months from the last CIED procedure (172; 54.09%). The most common early infections were PIs that were associated with the preceding CIED-related procedure. Late LRIE was most likely to occur in patients with intracardiac lead abrasion. The probability of early versus late LRIE was higher in patients with CoNS cultures. The timing of infection onset irrespective of its type does not affect long-term survival after transvenous lead extraction. The majority of infectious complications (69%) occur more than 12 months after the last CIED-related procedure. Early infections are probably associated with pocket contamination during CIED-related procedure, while delayed and late systemic infections are related to other lead-dependent factors (especially to intracardiac lead abrasion). Time to LRIE onset is associated with pathogen type. The timing of symptom onset does not affect long-term survival after TLE.
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Affiliation(s)
- Anna Polewczyk
- Department of Physiology, Pathophysiology and Clinical Immunology, Collegium Medicum of Jan Kochanowski University, 25-369 Kielce, Poland
- Department of Cardiac Surgery, Świętokrzyskie Cardiology Center, 25-736 Kielce, Poland
- Correspondence: ; Tel.: +48-600-024-074; Fax: +48-413-671-456
| | - Wojciech Jacheć
- 2nd Department of Cardiology, Zabrze, Faculty of Medical Science in Zabrze, Medical University of Silesia in Katowice, 40-055 Katowice, Poland;
| | - Maciej Polewczyk
- Department of Microbiology, Collegium Medicum of Jan Kochanowski University, 25-317 Kielce, Poland;
- Acute Cardiac Care Unit, Świętokrzyskie Cardiology Center, 25-736 Kielce, Poland
| | | | - Andrzej Kutarski
- Department of Cardiology, Medical University, 20-059 Lublin, Poland; (D.S.-S.); (A.K.)
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13
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Salvage of Cardiac Implantable Electronic Device Pocket Infection with Skin Erosion in Frail 92-Year-Old. J Cardiovasc Dev Dis 2022; 9:jcdd9030081. [PMID: 35323629 PMCID: PMC8955956 DOI: 10.3390/jcdd9030081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 02/01/2023] Open
Abstract
We reported the novel use of a taurolidine-containing antimicrobial solution in the successful salvage of a partially exposed and polymicrobially infected cardiac implantable electronic device pulse generator in a frail patient unfit for lead extraction. The old, salvaged device was entirely internalized, and there were no signs of recurrent infection at 9 months follow-up.
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14
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Olsen T, Justesen US, Nielsen JC, Jørgensen OD, Foldager Sandgaard NC, Ravn C, Gerdes C, Thøgersen AM, Gill S, Fuursted K, Johansen JB. Microbiological Diagnosis in Cardiac Implantable Electronic Device Infections Detected by Sonication and Next-Generation Sequencing. Heart Rhythm 2022; 19:901-908. [DOI: 10.1016/j.hrthm.2022.01.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/04/2022] [Accepted: 01/31/2022] [Indexed: 12/26/2022]
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15
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Lin G, Zou T, Dong M, Liu J, Cui W, Tong J, Shi H, Chen H, Chong J, Lyu Y, Wu S, Wang Z, Jin X, Gao X, Sun L, Qu Y, Yang J. Risk Stratifying and Prognostic Analysis of Subclinical Cardiac Implantable Electronic Devices Infection: Insight From Traditional Bacterial Culture. J Am Heart Assoc 2021; 10:e022260. [PMID: 34729993 PMCID: PMC8751915 DOI: 10.1161/jaha.121.022260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Subclinical infection of cardiac implantable electronic devices (CIEDs) is a common condition and increases the risk of clinical infection. However, there are limited studies focused on risk stratifying and prognostic analysis of subclinical CIED infection. Methods and Results Data from 418 consecutive patients undergoing CIED replacement or upgrade between January 2011 and December 2019 were used in the analysis. Among the patients included, 50 (12.0%) were detected as positive by bacterial culture of pocket tissues. The most frequently isolated bacteria were coagulase‐negative staphylococci (76.9%). Compared with the noninfection group, more patients in the subclinical infection group were taking immunosuppressive agents, received electrode replacement, or received CIED upgrade and temporary pacing. Patients in the subclinical infection group had a higher PADIT (Prevention of Arrhythmia Device Infection Trial) score. Univariable and multivariable logistic regression analysis found that use of immunosuppressive agents (odds ratio [OR], 6.95 [95% CI, 1.44–33.51]; P=0.02) and electrode replacement or CIED upgrade (OR, 6.73 [95% CI, 2.23–20.38]; P=0.001) were significantly associated with subclinical CIED infection. Meanwhile, compared with the low‐risk group, patients in the intermediate/high‐risk group had a higher risk of subclinical CIED infection (OR, 3.43 [95% CI, 1.58–7.41]; P=0.002). After a median follow‐up time of 36.5 months, the end points between the subclinical infection group and noninfection group were as follows: composite events (58.0% versus 41.8%, P=0.03), rehospitalization (54.0% versus 32.1%, P=0.002), cardiovascular rehospitalization (32.0% versus 13.9%, P=0.001), CIED infection (2.0% versus 0.5%, P=0.32), all‐cause mortality (28.0% versus 21.5%, P=0.30), and cardiovascular mortality (10.0% versus 7.6%, P=0.57). Conclusions Subclinical CIED infection was a common phenomenon. The PADIT score had significant value for stratifying patients at high risk of subclinical CIED infection. Subclinical CIED infection was associated with increased risks of composite events, rehospitalization, and cardiovascular rehospitalization.
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Affiliation(s)
- Gaofeng Lin
- Department of Cardiology Beijing Hospital National Center of Gerontology Institute of Geriatric Medicine Chinese Academy of Medical Sciences Beijing China.,Graduate School of Peking Union Medical College Chinese Academy of Medical Sciences Beijing China
| | - Tong Zou
- Department of Cardiology Beijing Hospital National Center of Gerontology Institute of Geriatric Medicine Chinese Academy of Medical Sciences Beijing China.,Graduate School of Peking Union Medical College Chinese Academy of Medical Sciences Beijing China
| | - Min Dong
- Department of Cardiology Beijing Hospital National Center of Gerontology Institute of Geriatric Medicine Chinese Academy of Medical Sciences Beijing China
| | - Junpeng Liu
- Department of Cardiology Beijing Hospital National Center of Gerontology Institute of Geriatric Medicine Chinese Academy of Medical Sciences Beijing China
| | - Wen Cui
- Department of Cardiology Beijing Hospital National Center of Gerontology Institute of Geriatric Medicine Chinese Academy of Medical Sciences Beijing China
| | - Jiabin Tong
- Department of Cardiology Beijing Hospital National Center of Gerontology Institute of Geriatric Medicine Chinese Academy of Medical Sciences Beijing China
| | - Haifeng Shi
- Department of Cardiology Beijing Hospital National Center of Gerontology Institute of Geriatric Medicine Chinese Academy of Medical Sciences Beijing China
| | - Hao Chen
- Department of Cardiology Beijing Hospital National Center of Gerontology Institute of Geriatric Medicine Chinese Academy of Medical Sciences Beijing China
| | - Jia Chong
- Department of Cardiology Beijing Hospital National Center of Gerontology Institute of Geriatric Medicine Chinese Academy of Medical Sciences Beijing China
| | - You Lyu
- Department of Cardiology Beijing Hospital National Center of Gerontology Institute of Geriatric Medicine Chinese Academy of Medical Sciences Beijing China
| | - Sujuan Wu
- Department of Cardiology Beijing Hospital National Center of Gerontology Institute of Geriatric Medicine Chinese Academy of Medical Sciences Beijing China
| | - Zhilei Wang
- Department of Cardiology Beijing Hospital National Center of Gerontology Institute of Geriatric Medicine Chinese Academy of Medical Sciences Beijing China
| | - Xin Jin
- Department of Cardiology Beijing Hospital National Center of Gerontology Institute of Geriatric Medicine Chinese Academy of Medical Sciences Beijing China
| | - Xu Gao
- Department of Cardiology Beijing Hospital National Center of Gerontology Institute of Geriatric Medicine Chinese Academy of Medical Sciences Beijing China
| | - Lin Sun
- Department of Cardiology Beijing Hospital National Center of Gerontology Institute of Geriatric Medicine Chinese Academy of Medical Sciences Beijing China
| | - Yimei Qu
- Department of Cardiology Beijing Hospital National Center of Gerontology Institute of Geriatric Medicine Chinese Academy of Medical Sciences Beijing China
| | - Jiefu Yang
- Department of Cardiology Beijing Hospital National Center of Gerontology Institute of Geriatric Medicine Chinese Academy of Medical Sciences Beijing China.,Graduate School of Peking Union Medical College Chinese Academy of Medical Sciences Beijing China
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16
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Tarakji KG, Krahn AD, Poole JE, Mittal S, Kennergren C, Biffi M, Korantzopoulos P, Dallaglio PD, Lexcen DR, Lande JD, Hilleren G, Holbrook R, Wilkoff BL. Risk Factors for CIED Infection After Secondary Procedures: Insights From the WRAP-IT Trial. JACC Clin Electrophysiol 2021; 8:101-111. [PMID: 34600848 DOI: 10.1016/j.jacep.2021.08.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/11/2021] [Accepted: 08/14/2021] [Indexed: 01/28/2023]
Abstract
OBJECTIVES This study aimed to identify risk factors for infection after secondary cardiac implantable electronic device (CIED) procedures. BACKGROUND Risk factors for CIED infection are not well defined and techniques to minimize infection lack supportive evidence. WRAP-IT (World-wide Randomized Antibiotic Envelope Infection Prevention trial), a large study that assessed the safety and efficacy of an antibacterial envelope for CIED infection reduction, offers insight into procedural details and infection prevention strategies. METHODS This analysis included 2,803 control patients from the WRAP-IT trial who received standard preoperative antibiotics but not the envelope (44 patients with major infections through all follow-up). A multivariate least absolute shrinkage and selection operator machine learning model, controlling for patient characteristics and procedural variables, was used for risk factor selection and identification. Risk factors consistently retaining predictive value in the model (appeared >10 times) across 100 iterations of imputed data were deemed significant. RESULTS Of the 81 variables screened, 17 were identified as risk factors with 6 being patient/device-related (nonmodifiable) and 11 begin procedure-related (potentially modifiable). Patient/device-related factors included higher number of previous CIED procedures, history of atrial arrhythmia, geography (outside North America and Europe), device type, and lower body mass index. Procedural factors associated with increased risk included longer procedure time, implant location (non-left pectoral subcutaneous), perioperative glycopeptide antibiotic versus nonglycopeptide, anticoagulant, and/or antiplatelet use, and capsulectomy. Factors associated with decreased risk of infection included chlorhexidine skin preparation and antibiotic pocket wash. CONCLUSIONS In WRAP-IT patients, we observed that several procedural risk factors correlated with infection risk. These results can help guide infection prevention strategies to minimize infections associated with secondary CIED procedures.
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Affiliation(s)
- Khaldoun G Tarakji
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA.
| | - Andrew D Krahn
- Center for Cardiovascular Innovation, Division of Cardiology, University of British Columbia Vancouver, British Columbia, Canada
| | - Jeanne E Poole
- Division of Cardiology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Suneet Mittal
- Electrophysiology, Valley Health System, Ridgewood, New Jersey, USA
| | - Charles Kennergren
- Cardiothoracic Surgery, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Mauro Biffi
- Department of Electrophysiology, Policlinico Sant' Orsola, Bologna. Italy
| | | | | | - Daniel R Lexcen
- Cardiac Rhythm Management, Medtronic, Mounds View, Minnesota, USA, (j)Department of Cardiovascular Medicine, Cleveland Clinic, Ohio, USA
| | - Jeff D Lande
- Cardiac Rhythm Management, Medtronic, Mounds View, Minnesota, USA, (j)Department of Cardiovascular Medicine, Cleveland Clinic, Ohio, USA
| | - Gregory Hilleren
- Cardiac Rhythm Management, Medtronic, Mounds View, Minnesota, USA, (j)Department of Cardiovascular Medicine, Cleveland Clinic, Ohio, USA
| | - Reece Holbrook
- Cardiac Rhythm Management, Medtronic, Mounds View, Minnesota, USA, (j)Department of Cardiovascular Medicine, Cleveland Clinic, Ohio, USA
| | - Bruce L Wilkoff
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
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17
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Frausing MHJP, Kronborg MB, Johansen JB, Nielsen JC. Avoiding implant complications in cardiac implantable electronic devices: what works? Europace 2021; 23:163-173. [PMID: 33063088 DOI: 10.1093/europace/euaa221] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/08/2020] [Indexed: 01/14/2023] Open
Abstract
Nearly one in ten patients experience complications in relation to cardiac implantable electronic device (CIED) implantations. CIED complications have serious implications for the patients and for the healthcare system. In light of the rising rates of new implants and consistent rate of complications, primary prevention remains a major concern. To guide future efforts, we sought to review the evidence base underlying common preventive actions made during a primary CIED implantation.
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Affiliation(s)
| | - Mads Brix Kronborg
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Bvld. 99, DK-8200, Aarhus, Denmark
| | - Jens Brock Johansen
- Department of Cardiology, Odense University Hospital, J. B. Winsløvs Vej 4, DK-5000, Odense, Denmark
| | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Bvld. 99, DK-8200, Aarhus, Denmark
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18
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Blomström-Lundqvist C, Traykov V, Erba PA, Burri H, Nielsen JC, Bongiorni MG, Poole J, Boriani G, Costa R, Deharo JC, Epstein LM, Saghy L, Snygg-Martin U, Starck C, Tascini C, Strathmore N. 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). Europace 2021; 22:515-549. [PMID: 31702000 PMCID: PMC7132545 DOI: 10.1093/europace/euz246] [Citation(s) in RCA: 186] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 08/19/2019] [Indexed: 01/28/2023] Open
Abstract
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.
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Affiliation(s)
| | - Vassil Traykov
- Department of Invasive Electrophysiology and Cardiac Pacing, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Paola Anna Erba
- Nuclear Medicine, Department of Translational Research and New Technology in Medicine, University of Pisa, Pisa, Italy, and University of Groningen, University Medical Center Groningen, Medical Imaging Center, Groningen, The Netherlands
| | - Haran Burri
- Department of Cardiology, University Hospital of Geneva, Geneva, Switzerland
| | | | - Maria Grazia Bongiorni
- Division of Cardiology and Arrhythmology, CardioThoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
| | - Jeanne Poole
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Giuseppe Boriani
- Division of Cardiology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Roberto Costa
- Department of Cardiovascular Surgery, Heart Institute (InCor) of the University of São Paulo, São Paulo, Brazil
| | - Jean-Claude Deharo
- Department of Cardiology, Aix Marseille Université, CHU la Timone, Marseille, France
| | - Laurence M Epstein
- Electrophysiology, Northwell Health, Hofstra/Northwell School of Medicine, Manhasset, NY, USA
| | - Laszlo Saghy
- Division of Electrophysiology, 2nd Department of Medicine and Cardiology Centre, University of Szeged, Szeged, Hungary
| | - Ulrika Snygg-Martin
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Christoph Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Carlo Tascini
- First Division of Infectious Diseases, Cotugno Hospital, Azienda ospedaliera dei Colli, Naples, Italy
| | - Neil Strathmore
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
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19
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Blomström-Lundqvist C, Traykov V, Erba PA, Burri H, Nielsen JC, Bongiorni MG, Poole J, Boriani G, Costa R, Deharo JC, Epstein LM, Saghy L, Snygg-Martin U, Starck C, Tascini C, Strathmore N. 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). Eur J Cardiothorac Surg 2021; 57:e1-e31. [PMID: 31724720 DOI: 10.1093/ejcts/ezz296] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 08/19/2019] [Indexed: 12/26/2022] Open
Abstract
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.
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Affiliation(s)
| | - Vassil Traykov
- Department of Invasive Electrophysiology and Cardiac Pacing, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Paola Anna Erba
- Nuclear Medicine, Department of Translational Research and New Technology in Medicine, University of Pisa, Pisa, Italy, and University of Groningen, University Medical Center Groningen, Medical Imaging Center, Groningen, Netherlands
| | - Haran Burri
- Department of Cardiology, University Hospital of Geneva, Geneva, Switzerland
| | | | - Maria Grazia Bongiorni
- Division of Cardiology and Arrhythmology, CardioThoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
| | - Jeanne Poole
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Giuseppe Boriani
- Division of Cardiology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Roberto Costa
- Department of Cardiovascular Surgery, Heart Institute (InCor) of the University of São Paulo, São Paulo, Brazil
| | - Jean-Claude Deharo
- Department of Cardiology, Aix Marseille Université, CHU la Timone, Marseille, France
| | - Laurence M Epstein
- Electrophysiology, Northwell Health, Hofstra/Northwell School of Medicine, Manhasset, NY, USA
| | - Laszlo Saghy
- Division of Electrophysiology, 2nd Department of Medicine and Cardiology Centre, University of Szeged, Szeged, Hungary
| | - Ulrika Snygg-Martin
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Christoph Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Carlo Tascini
- First Division of Infectious Diseases, Cotugno Hospital, Azienda ospedaliera dei Colli, Naples, Italy
| | - Neil Strathmore
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
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20
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A Review of Cardiac Implantable Electronic Device Infections for the Practicing Electrophysiologist. JACC Clin Electrophysiol 2021; 7:811-824. [PMID: 34167758 DOI: 10.1016/j.jacep.2021.03.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/25/2021] [Accepted: 03/27/2021] [Indexed: 11/20/2022]
Abstract
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.
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Blomström-Lundqvist C, Traykov V, Erba PA, Burri H, Nielsen JC, Bongiorni MG, Poole J, Boriani G, Costa R, Deharo JC, Epstein LM, Sághy L, Snygg-Martin U, Starck C, Tascini C, Strathmore N. 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). Eur Heart J 2021; 41:2012-2032. [PMID: 32101604 DOI: 10.1093/eurheartj/ehaa010] [Citation(s) in RCA: 101] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 10/07/2019] [Accepted: 01/10/2020] [Indexed: 01/07/2023] Open
Abstract
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.
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Affiliation(s)
| | - Vassil Traykov
- Department of Invasive Electrophysiology and Cardiac Pacing, Acibadem City Clinic Tokuda Hospital, Nikola Vaptsarov blvd 51 B, 1 407 Sofia, Bulgaria
| | - Paola Anna Erba
- Department of Translational Research and New Technology in Medicine, University of Pisa-AOUP, Lungarno Antonio Pacinotti, 43, 56126 Pisa PI, Italy.,Department of Nuclear Medicine & Molecular Imaging University Medical Center Groningen, University of Groningen, 9712 CP Groningen, Netherlands
| | - Haran Burri
- Department of Cardiology, University Hospital of Geneva, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland
| | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Blvd. 161, 8200 Aarhus, Denmark
| | - Maria Grazia Bongiorni
- CardioThoracic and Vascular Department, University Hospital of Pisa, Via Paradisa 2, 56125 Pisa PI, Italy
| | - Jeanne Poole
- Department of Cardiology, University of Washington, Roosevelt Way NE, Seattle, WA 98115, USA
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Largo del Pozzo, 71, 41125 Modena, Italy
| | - Roberto Costa
- Department of Cardiovascular Surgery, Heart Institute (InCor) of the University of São Paulo, Butanta, São Paulo - State of São Paulo, Brazil
| | - Jean-Claude Deharo
- Department of Cardiology, Aix Marseille Université, CHU la Timone, 278 Rue Saint-Pierre, 13005 Marseille, France
| | - Laurence M Epstein
- Electrophysiology, Northwell Health, Hofstra/Northwell School of Medicine, 300 Community Drive, Manhasset, NY 11030, USA
| | - László Sághy
- Electrophysiology Division, 2nd Department of Medicine and Cardiology Centre, University of Szeged, Aradi vértanúk tere 1, 6720 Szeged, Hungary
| | - Ulrika Snygg-Martin
- Department of Infectious Diseases, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden
| | - Christoph Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Augustenburger Pl. 1, 13353 Berlin, Germany
| | - Carlo Tascini
- First Division of Infectious Diseases, Cotugno Hospital, Azienda ospedaliera dei Colli, Via Gaetano Quagliariello, 54, 80131 Napoli NA, Italy
| | - Neil Strathmore
- Department of Cardiology, Royal Melbourne Hospital, 300 Grattan St, Parkville VIC 3050, Melbourne, Australia
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Barbar T, Patel R, Thomas G, Cheung JW. Strategies to Prevent Cardiac Implantable Electronic Device Infection. J Innov Card Rhythm Manag 2020; 11:3949-3956. [PMID: 32368364 PMCID: PMC7192142 DOI: 10.19102/icrm.2020.110102] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 10/16/2019] [Indexed: 12/15/2022] Open
Abstract
The association between the risk of mortality and cardiovascular implantable electronic device (CIED) infections has been well-established in the literature. As CIED implantations have increased in frequency in the past few decades, the incidence of CIED-related infections has also risen. Given the morbidity, mortality, and health-care costs associated with CIED infections, the prevention of device-related infection is a critical goal. Risk factors for developing CIED infections can be categorized as patient-, procedure-, or device-related. Numerous studies have highlighted different strategies for preventing CIED-related infections, which include patient optimization, device selection, and periprocedural preparation and treatment. Nonetheless, as the comorbidity burden of patients undergoing CIED implantation continues to increase, significant challenges in the successful elimination of CIED-related infections remain. This review provides a comprehensive overview of available evidence-based approaches and strategies to reduce the risk of CIED infections.
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Affiliation(s)
- Tarek Barbar
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine-New York Presbyterian Hospital, New York, NY, USA
| | - Rohan Patel
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine-New York Presbyterian Hospital, New York, NY, USA
| | - George Thomas
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine-New York Presbyterian Hospital, New York, NY, USA
| | - Jim W Cheung
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine-New York Presbyterian Hospital, New York, NY, USA
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Single- and dual-site ventricular pacing entirely through the coronary sinus for patients with prior tricuspid valve surgery. J Interv Card Electrophysiol 2019; 56:79-89. [PMID: 31432385 DOI: 10.1007/s10840-019-00599-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 07/16/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Transvenous right ventricular pacing has traditionally been avoided after surgical tricuspid valve repair or replacement because of possible valvular dysfunction. Epicardial pacing has been used but it requires surgical thoracotomy and has higher lead failure rates when compared to transvenous pacing. We evaluated the lead stability and clinical outcomes in patients with isolated coronary sinus (CS) lead due to relative contraindication to transvenous pacing from prior tricuspid valve (TV) surgery. METHODS We retrospectively examined a single-center cohort of 34 patients with TV disease and/or surgery who underwent permanent pacemaker implantation with a left ventricular CS lead as the only ventricular pacing lead (to avoid crossing the TV). The clinical outcome, echocardiographic data, and pacing thresholds were evaluated at follow-up. RESULTS We implanted 19 patients with a single-CS lead and 15 patients with dual-CS leads. The average left ventricular ejection fraction was 56 ± 13% prior to lead implantation and remained stable at 2-year follow-up. The tricuspid regurgitation remained mild at follow-up. The average lead pacing threshold was 1.2 ± 0.6 V × ms at implant and 1.1 ± 0.4 V × ms at 2-year follow-up (P = 0.39). For patients with dual-CS leads, the pacing threshold was 1.2 ± 0.7 V × ms at implant and 1.1 ± 0.5 V × ms at 2-year follow-up (P = 0.52). CONCLUSIONS The use of ventricular pacing entirely through the CS is an effective and minimally invasive method that provides stable pacing for patients with prior TV surgery in whom transvenous lead placement either is not possible or is relatively contraindicated.
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Kleemann T, Strauss M, Kouraki K, Lampropoulou E, Fendt A, Werner N, Zahn R. Contemporary benefit-harm profile over two decades in primary prophylactic ICD-therapy. Clin Cardiol 2019; 42:866-872. [PMID: 31317573 PMCID: PMC6788478 DOI: 10.1002/clc.23234] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 06/28/2019] [Accepted: 07/08/2019] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Implantable cardioverter defibrillator (ICD) was implemented into clinical routine more than 20 years ago. Since then, ICD therapy became standard therapy for primary and secondary prevention of sudden cardiac death in clinical practice. OBJECTIVES Aim of the study was to evaluate the benefit-harm profile of contemporary primary prophylactic ICD therapy. METHODS A total of 1222 consecutive patients of a prospective single-center ICD-registry were analyzed who underwent primary prophylactic ICD implantation between 2000 and 2017. Patients were divided into two groups according to the implantation year: 2010-2017 (group 1, n = 579) and 2000-2009 (group 2, n = 643). RESULTS The rate of estimated appropriate ICD therapy after 8 years was 51% in the 2000s and 42% in the 2010s (P < .001). The complication rate changed slightly from 53% to 47% (P = .005). This decline was mainly driven by the reduction of inappropriate ICD shocks (30% vs 14%, P < .001) whereas the rate of ICD shock lead malfunction and device/ lead infection remained unchanged over time. Nonischemic cardiomyopathy was an independent predictor for ICD complications without benefit of ICD therapy (HR 1.37, 95% CI 1.07-1.77). CONCLUSION The ICD therapy rate for ventricular arrhythmias in patients with primary prophylactic ICD implantation is decreasing over the last two decades. Complication rate remains high due to an unchanged rate of ICD shock malfunctions and device infections. Nonischemic cardiomyopathy is an independent predictor for ICD complications without benefit of ICD therapy in primary prophylactic ICD-therapy.
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Affiliation(s)
- Thomas Kleemann
- Klinikum Ludwigshafen, Medizinische Klinik B, Ludwigshafen, Germany
| | - Margit Strauss
- Klinikum Ludwigshafen, Medizinische Klinik B, Ludwigshafen, Germany
| | | | | | - Andràs Fendt
- Klinikum Ludwigshafen, Medizinische Klinik B, Ludwigshafen, Germany
| | - Nicolas Werner
- Klinikum Ludwigshafen, Medizinische Klinik B, Ludwigshafen, Germany
| | - Ralf Zahn
- Klinikum Ludwigshafen, Medizinische Klinik B, Ludwigshafen, Germany
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Biffi M. The never-ending story of CIED infection prevention: Shall we WRAP-IT and go? J Cardiovasc Electrophysiol 2019; 30:1191-1196. [PMID: 31172637 DOI: 10.1111/jce.14010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 05/28/2019] [Indexed: 12/01/2022]
Abstract
CIED infection is perceived as substantial, ranging from 1% to 4% in literature depending on different studies and on the population profile, and can appear either as surgical site or endovascular infection or both. Several factors have been found to be associated to CIED infection, that can be summarized as patient-related (clinical profile, associated comorbidities, ongoing treatment as anticoagulants and immunosuppressants), Procedure-related (complexity of CIED surgery, type of surgery, previous pocket exploration), and center-/operator-related (center/operator volume). Thus, it is difficult to disentangle the extent of benefit that any intervention may offer to decrease this threatened complication, owing to its multifaceted complexity. The recently completed PADIT and WRAP-IT trials have significantly improved our knowledge in this field (nearly 20 000 patients enrolled), reporting an infection rate of 1% to 1.2% in control-arm patients and a 20% to 67% infection decrease when incremental antibiotic prophylaxis is added on top of optimized preventative strategies. Observational registries highlighted that participation in a prospective survey of CIED infection dramatically decrease infection rate by optimization of antisepsis protocols and operator awareness, that explains the low event rate observed in PADIT and WRAP-IT. While this consideration prompts each center to engage into a proactive infection prevention program, it makes a point in favor of antibiotic prophylaxis delivered locally in 7 days or more, as enabled by TYRX in the WRAP-IT trial. However, care sustainability (the number needed to treat in the most favorable WRAP-IT scenario is 100) suggests further analysis to understand the settings (patient- or procedure-related) most likely to benefit by such an enhanced prevention strategy.
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Affiliation(s)
- Mauro Biffi
- Cardiothoracic and Vascular Department, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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26
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Goldenberg GR, Barsheshet A, Bishara J, Kadmon E, Omelchencko A, Strasberg B, Golovchiner G. Effect of fibrotic capsule debridement during generator replacement on cardiac implantable electronic device infection risk. J Interv Card Electrophysiol 2019; 58:113-118. [PMID: 31227978 DOI: 10.1007/s10840-019-00581-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 06/12/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cardiovascular implantable electronic device (CIED) replacement is increasingly common. It has been proposed that capsule removal at the time of CIED replacement may reduce infection rates. In this study, we aimed to assess how pocket capsule removal impacted infection rates in patients undergoing CIED replacement. METHODS We retrospectively reviewed the medical records of patients who underwent CIED replacement from 2006 to 2016 at a single centre. We retrieved patient data, procedure details, and clinical outcomes. To evaluate the relationship between capsule removal and CIED infection, we used the Cox proportional hazard model, with adjustment for multiple variables. RESULTS During the study period, 773 patients underwent device replacement. Of these patients, 194 (25%) underwent capsule debridement during the replacement procedure. The mean patient age was 75 ± 15 years, and 281 (36.3%) were females. The replaced CIEDs included DDD pacemakers (32%), VDD pacemakers (15%), VVI/AAI pacemakers (13%), defibrillators (22%), and cardiac resynchronization therapy devices (CRT-D/P) (17%). During an average follow-up of 3.6 years, 42 (5%) patients experienced a CIED infection. Multivariate analysis revealed that patients who underwent capsule removal had a significantly lower risk of CIED infection, with a hazard ratio of 0.32 (95% confidence interval, 0.12-0.83; P = 0.019). CONCLUSIONS Capsule debridement during CIED replacement was associated with a significant reduction of CIED infection risk. There is a need for randomized controlled studies to confirm these findings.
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Affiliation(s)
- Gustavo R Goldenberg
- Electrophysiology and Pacing Unit, Department of Cardiology, Rabin Medical Center, Ze'ev Jabotinsky St 39, 4941492, Petah Tikva, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel.
| | - Alon Barsheshet
- Electrophysiology and Pacing Unit, Department of Cardiology, Rabin Medical Center, Ze'ev Jabotinsky St 39, 4941492, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Jihad Bishara
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
- Infectious Diseases Unit, Rabin Medical Center, Petah Tikva, Israel
| | - Ehud Kadmon
- Electrophysiology and Pacing Unit, Department of Cardiology, Rabin Medical Center, Ze'ev Jabotinsky St 39, 4941492, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Alex Omelchencko
- Electrophysiology and Pacing Unit, Department of Cardiology, Rabin Medical Center, Ze'ev Jabotinsky St 39, 4941492, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Boris Strasberg
- Electrophysiology and Pacing Unit, Department of Cardiology, Rabin Medical Center, Ze'ev Jabotinsky St 39, 4941492, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Gregory Golovchiner
- Electrophysiology and Pacing Unit, Department of Cardiology, Rabin Medical Center, Ze'ev Jabotinsky St 39, 4941492, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
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Biffi M, Ammendola E, Menardi E, Parisi Q, Narducci ML, De Filippo P, Manzo M, Stabile G, Potenza DR, Zanon F, Quartieri F, Rillo M, Saporito D, Zacà V, Berisso MZ, Bertini M, Tumietto F, Malacrida M, Diemberger I. Real-life outcome of implantable cardioverter-defibrillator and cardiac resynchronization defibrillator replacement/upgrade in a contemporary population: observations from the multicentre DECODE registry. Europace 2019; 21:1527-1536. [DOI: 10.1093/europace/euz166] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 05/22/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
Aims
The benefit of prolonged implantable cardioverter-defibrillator (ICD)/cardiac resynchronization therapy defibrillator (CRT-D) therapy following device replacement is hindered by clinical and procedure-related adverse events (AEs). Adverse events rate is highest in more complex devices and at upgrades, as per the REPLACE registry experience, but is changing owing to the improvement in device technology and medical care. We aimed at understanding the extent and type of AEs in a contemporary Italian population.
Methods and results
Detect long-term complications after ICD replacement (DECODE) was a prospective, single-arm, multicentre cohort study aimed at estimating medium- to long-term AEs in a large population of patients undergoing ICD/cardiac resynchronization defibrillator replacement/upgrade from 2013 to 2015. We prospectively analysed all clinical and device-related AEs at 12-month follow-up (FU) of 983 consecutive patients (median age 71 years, 76% male, 55% ischaemic, 47% CRT-D) followed for 353 ± 49 days. Seven percent of the patients died (60.6% for cardiovascular reasons), whereas 104 AEs occurred; 43 (4.4%) patients needed at least one surgical action to treat the AE. Adverse events rates were 3.3/100 years lead-related, 3.4/100 years bleedings, and 1.6/100 years infective. The primary endpoint was predicted by hospitalization in the month prior to the procedure [hazard ratio (HR) = 2.23, 1.16–4.29; 0.0169] and by upgrade (HR = 1.75, 1.02–2.99, 0.0441). One hundred and twelve (11.4%) patients met the combined endpoint of death from any cause, cardiac implantable electronic device (CIED)-related infection, and surgical action/hospitalization required to treat the AE. Hospitalization within 30 days prior to the procedure (HR = 2.07, 1.13–3.81; 0.0199), anticoagulation (HR = 1.97, 1.26–3.07; 0.003), and ischaemic cardiomyopathy (HR = 1.67, 95% confidence interval 1.06–2.63; P = 0.0276) were associated with the combined endpoint during FU.
Conclusions
Adverse events following CIED replacement/upgrade are lower than previously reported, possibly owing to improved patients care. Hospitalization in the month prior to the procedure, upgrade, and clinical profile (anticoagulation, ischaemic cardiomyopathy) hint to increased risk, suggesting an individualized planning of the procedure to minimize overall AEs.
Clinical trial registration
URL: http://clinicaltrials.gov/ Identifier: NCT02076789.
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Affiliation(s)
- Mauro Biffi
- Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti n. 9, Bologna, Italy
| | | | | | - Quintino Parisi
- Fondazione di Ricerca e Cura Giovanni Paolo II, Campobasso, Italy
| | | | | | - Michele Manzo
- A.O. Universitaria S. Giovanni Di Dio e Ruggi D’Aragona, Salerno, Italy
| | | | | | | | - Fabio Quartieri
- A.O. IRCCS Arcispedale S. Maria Nuova Di Reggio Emilia, Reggio Emilia, Italy
| | | | | | - Valerio Zacà
- Arrhythmology Unit, Cardiovascular and Thoracic Department, AOU Senese, Siena, Italy
| | | | - Matteo Bertini
- Azienda Ospedaliero Universitaria Di Ferrara Arcispedale S. Anna, Ferrara, Italy
| | - Fabio Tumietto
- Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti n. 9, Bologna, Italy
| | | | - Igor Diemberger
- Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti n. 9, Bologna, Italy
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28
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Oh IY. Small but Persistent Infection of Cardiac Implantable Electronic Devices (CIED). Korean Circ J 2019; 49:753-754. [PMID: 31165600 PMCID: PMC6675694 DOI: 10.4070/kcj.2019.0134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 05/07/2019] [Indexed: 11/11/2022] Open
Affiliation(s)
- Il-Young Oh
- Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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29
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Biffi M, de Zan G, Massaro G, Angeletti A, Martignani C, Boriani G, Diemberger I, Ziacchi M. Is ventricular sensing always right, when it is left? Clin Cardiol 2018; 41:1238-1245. [PMID: 30054904 DOI: 10.1002/clc.23033] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 07/21/2018] [Accepted: 07/25/2018] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Ventricular sensing in transvenous cardiac implantable electronic devices (CIEDs) occurs conventionally from the right ventricular (RV) channel, though it evolved from epicardial sensing both in pacemakers and implantable cardioverter-defibrillators (ICDs). HYPOTHESIS The objective of this study was to observe the reliability of left ventricular (LV) sensing by transvenous leads placed in coronary veins. METHODS LV leads were used for sensing and arrhythmia detection in clinical situations where placement of an RV lead across the tricuspid valve was either not preferred or not feasible, or RV signal was unsuitable for arrhythmia detection, or in the event of sensing failure of an RV lead under advisory in cardiac resynchronization therapy defibrillator (CRTD) recipients. RESULTS Thirty-seven patients had an IS-1 LV lead connected to the RV port of CIEDs (17 pacemakers, 5 cardiac resynchronization therapy pacemaker [CRTP], 2 ICDs, and 13 CRTDs). Along a median 41 (25-67) months follow-up, lead performance remained stable; there were neither undersensing nor oversensing of non-cardiac signals. VT/VF were correctly detected and terminated by ATP and shocks (one and three patients, respectively); no inappropriate arrhythmia detection. Device reprogramming occurred in four CRTD recipients because of transient counting the QRS (short intervals) when paced in LV-only, and in two with T-wave oversensing. CONCLUSIONS Ventricular sensing by an LV lead is feasible in transvenous devices. Sensing programmability is an unmet need: to fix RV lead sensing issues in cardiac resynchronization therapy (CRT) recipients at no risk of infection (no pocket opening); to avoid interaction with the tricuspid valve; to avoid lead redundancy in the vasculature. Moreover, it will be mandatory owing to the loss of lead interchangeability due to the adoption of DF-4 and quadripolar leads.
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Affiliation(s)
- Mauro Biffi
- Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giulia de Zan
- Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giulia Massaro
- Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | | | | | - Igor Diemberger
- Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Matteo Ziacchi
- Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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30
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Boriani G, Merino J, Wright DJ, Gadler F, Schaer B, Landolina M. Battery longevity of implantable cardioverter-defibrillators and cardiac resynchronization therapy defibrillators: technical, clinical and economic aspects. An expert review paper from EHRA. Europace 2018; 20:1882-1897. [DOI: 10.1093/europace/euy066] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 05/02/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Diagnostics, Clinical and Public Health Medicine, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Josè Merino
- Arrhythmia and Robotic Electrophysiology Unit, Hospital Universitario La Paz, Universidad Europea, Madrid, Spain
| | - David J Wright
- Cardiology Division, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Fredrik Gadler
- Heart and Vascular Theme, Karolinska Institute of Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Beat Schaer
- Department of Cardiology, University Hospital of Basel, Switzerland
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31
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Harper MW, Uslan DZ, Greenspon AJ, Baddour LM, Carrillo RG, Danik SB, Tolosana JM, Le K, Miro JM, Naber CK, Peacock J, Sohail MR, Vikram HR, Prutkin JM. Clinical presentation of CIED infection following initial implant versus reoperation for generator change or lead addition. Open Heart 2018; 5:e000681. [PMID: 29632673 PMCID: PMC5888434 DOI: 10.1136/openhrt-2017-000681] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 02/01/2018] [Accepted: 03/06/2018] [Indexed: 11/11/2022] Open
Abstract
Objective To explore differences in clinical manifestations and outcomes in those patients who develop infection after undergoing initial implantation versus reoperation. Methods We compared cases of cardiac implantable electronic device (CIED) infection based on initial implantation versus reoperation from 11 centres. Results There were 432 patients with CIED infection, 178 occurring after initial device placement and 254 after repeat reoperation. No differences were seen in age, sex or device type. Those with infection after initial implant had a higher Charlson Comorbidity Score (median 3 (IQR 2–6) vs 2 (IQR 1–4), p<0.001), shorter time since last procedure (median 8.9 months (IQR 0.9–33.3) vs 19.5 months (IQR 1.1–62.9), p<0.0001) and fewer leads (2.0±0.6vs 2.5±0.9, p<0.001). Pocket infections were more likely to occur after a reoperation (70.1%vs48.9%, p<0.001) and coagulase negative staphylococci (CoNS) was the most frequently isolated organism in this group (p=0.029). In contrast, initial implant infections were more likely to present with higher white cell count (10.5±5.1 g/dL vs 9.5±5.4 g/dL, p=0.025), metastatic foci of infection (16.9%vs8.7%, p=0.016) and sepsis (30.9%vs19.3%, p=0.006). There were no differences in in-hospital (7.9%vs5.2%, p=0.31) or 6-month mortality (21.9%vs14.0%, p=0.056). Conclusions CIED infections after initial device implant occur earlier, more aggressively, and often due to Staphylococcus aureus. In contrast, CIED infections after reoperation occur later, are due to CoNS, and have more indolent manifestations with primary localisation to the pocket.
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Affiliation(s)
- Mariko W Harper
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Daniel Z Uslan
- Division of Infectious Diseases, Department of Medicine, UCLA, Los Angeles, California, USA
| | - Arnold J Greenspon
- Division of Cardiology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Larry M Baddour
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Roger G Carrillo
- Division of Cardiothoracic Surgery, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Stephan B Danik
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jose M Tolosana
- Infectious Diseases Service, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Katherine Le
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Jose M Miro
- Infectious Diseases Service, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Christoph K Naber
- Klinik für Kardiologie und Angiologie, Elisabeth Krankenhaus, Essen, Germany
| | - James Peacock
- Section on Infectious Diseases, Department of Medicin, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Muhammad Rizwan Sohail
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Holenarasipur R Vikram
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Jordan M Prutkin
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington, USA
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Okuda KI, Nagahori R, Yamada S, Sugimoto S, Sato C, Sato M, Iwase T, Hashimoto K, Mizunoe Y. The Composition and Structure of Biofilms Developed by Propionibacterium acnes Isolated from Cardiac Pacemaker Devices. Front Microbiol 2018; 9:182. [PMID: 29491850 PMCID: PMC5817082 DOI: 10.3389/fmicb.2018.00182] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 01/26/2018] [Indexed: 11/13/2022] Open
Abstract
The present study aimed to understand the biofilm formation mechanism of Propionibacterium acnes by analyzing the components and structure of the biofilms. P. acnes strains were isolated from the surface of explanted cardiac pacemaker devices that exhibited no clinical signs of infection. Culture tests using a simple stamp culture method (pressing pacemakers against the surface of agar plates) revealed frequent P. acnes colonization on the surface of cardiac pacemaker devices. P. acnes was isolated from 7/31 devices, and the isolates were categorized by multilocus sequence typing into five different sequence types (STs): ST4 (JK18.2), ST53 (JK17.1), ST69 (JK12.2 and JK13.1), ST124 (JK5.3), ST125 (JK6.2), and unknown ST (JK19.3). An in vitro biofilm formation assay using microtiter plates demonstrated that 5/7 isolates formed biofilms. Inhibitory effects of DNase I and proteinase K on biofilm formation varied among isolates. In contrast, dispersin B showed no inhibitory activity against all isolates. Three-dimensional live/dead imaging of P. acnes biofilms with different biochemical properties using confocal laser microscopy demonstrated different distributions and proportions of living and dead cells. Additionally, it was suggested that extracellular DNA (eDNA) plays a role in the formation of biofilms containing living cells. Ultrastructural analysis of P. acnes biofilms using a transmission electron microscope and atmospheric scanning electron microscope revealed leakage of cytoplasmic components along with cell lysis and fibrous structures of eDNA connecting cells. In conclusion, the biochemical properties and structures of the biofilms differed among P. acnes isolates. These findings may provide clues for establishing countermeasures against biofilm-associated infection by P. acnes.
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Affiliation(s)
- Ken-Ichi Okuda
- Department of Bacteriology, The Jikei University School of Medicine, Tokyo, Japan.,Jikei Center for Biofilm Science and Technology, Tokyo, Japan
| | - Ryuichi Nagahori
- Department of Cardiac Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Satomi Yamada
- Department of Bacteriology, The Jikei University School of Medicine, Tokyo, Japan
| | - Shinya Sugimoto
- Department of Bacteriology, The Jikei University School of Medicine, Tokyo, Japan.,Jikei Center for Biofilm Science and Technology, Tokyo, Japan
| | - Chikara Sato
- Biomedical Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), Tsukuba, Japan
| | - Mari Sato
- Biomedical Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), Tsukuba, Japan
| | - Tadayuki Iwase
- Department of Bacteriology, The Jikei University School of Medicine, Tokyo, Japan.,Jikei Center for Biofilm Science and Technology, Tokyo, Japan
| | - Kazuhiro Hashimoto
- Department of Cardiac Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoshimitsu Mizunoe
- Department of Bacteriology, The Jikei University School of Medicine, Tokyo, Japan.,Jikei Center for Biofilm Science and Technology, Tokyo, Japan
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Abstract
Cardiac implantable electronic device (CIED) infections are complex medical problems that are increasingly encountered. They are associated with significant morbidity and mortality with tremendous economic cost. The current review will emphasize the prevention, diagnosis, and treatment of this clinical entity using the relatively limited evidence that is currently available. Because there is a paucity of high quality evidence regarding prevention, diagnosis, and treatment of CIED infections, this review will attempt to summarize the best evidence as well as to suggest, when possible, paradigms for care. The topic of CIED infections is a dynamic one as the scope of CIED continues to widen. Furthermore, there are promising advancements in CIED technology which may help reduce its occurrence the future. Unfortunately, significant gaps in knowledge remain, and definitive recommendations regarding CIED infections and future studies should be directed at improving our ability to prevent infections.
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Affiliation(s)
- Steven Leung
- Department of Medicine, Mount Sinai Beth Israel, First Avenue at 16th Street, New York, NY, 10003, USA
| | - Stephan Danik
- Department of Cardiology, Mount Sinai Beth Israel, First Avenue at 16th Street, New York, NY, 10003, USA.
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Gleva MJ, Poole JE. Prevention of Cardiac Implantable Electronic Device Infections: Update and Evaluation of the Potential Role for Capsulectomy or the Antibiotic Pouch. J Atr Fibrillation 2017; 9:1540. [PMID: 29250274 DOI: 10.4022/jafib.1540] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 01/18/2017] [Accepted: 01/24/2017] [Indexed: 11/10/2022]
Abstract
Cardiac implantable electronic device (CIED) infections can have devastating implications for patient morbidity and mortality. Over the past decade, the infection rate has risen out of proportion to implant rates, and has prompted the development of innovative solutions designed to reduce infections. The first section of this review provides a summary of the contemporary knowledge regarding the incidence, prevalence, microbiology, and risk factors for cardiac implantable electronic device infections. The second section addresses prevention with an emphasis on the potential role of novel procedural approaches, such as capsulectomy and the antibacterial envelope, in reducing CIED infection.
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Affiliation(s)
- Marye J Gleva
- Washington University in St. Louis School of Medicine, St. Louis,MO
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Tarakji KG, Ellis CR, Defaye P, Kennergren C. Cardiac Implantable Electronic Device Infection in Patients at Risk. Arrhythm Electrophysiol Rev 2016; 5:65-71. [PMID: 27403296 DOI: 10.15420/aer.2015.27.2] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
| | - Christopher R Ellis
- Vanderbilt Heart and Vascular Institute at Vanderbilt University, Nashville, Tennessee, US
| | - Pascal Defaye
- Centre Hospitalier Universitaire de Grenoble, La Tronche, France
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Cardiac device infection: Review based in the experience of a single center. Rev Port Cardiol 2016; 35:351-8. [PMID: 27255172 DOI: 10.1016/j.repc.2015.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 12/20/2015] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION The incidence of cardiac implantable electronic device infections has increased significantly over the years and they are associated with significant morbidity and mortality. The epidemiology in the Central region of Portugal is not known. OBJECTIVE AND METHODS To characterize cardiac implantable electronic device infections through a retrospective study of 3158 patients admitted to our center between January 2008 and September 2014 and to review the subject in the light of the current state of the art. RESULTS The infection rate was 1.48% (pacemakers 1.21%, cardiac defibrillator/resynchronization devices 5.40%). The study population consisted of 47 patients with a mean age of 65±19 years, predominantly male (72.3%). Infections were mainly of pacemakers, the main device implanted in our population (n=2954), and most occurred late after first implantation. Clinically, most patients presented with fever and local inflammation. Blood cultures identified mainly Gram-positive microorganisms. Empiric antibiotic therapy with vancomycin was instituted in all patients, associated with gentamicin in 57%. The device was extracted in the majority of cases (72%). During follow-up (32±22 months) eight patients died (17%), seven of cardiovascular cause (15%), and seven were readmitted with device infection (15%). CONCLUSIONS Our rate of infection was low, similar to other published series, with a higher rate in cardiac defibrillator/resynchronization devices. After standard treatment with antibiotic therapy and device extraction, the prognosis was good.
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Fernandes A, Cassandra M, Trigo J, Nascimento J, Carmo Cachulo M, Providência R, Costa M, Gonçalves L. Cardiac device infection: Review based on the experience of a single center. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.repce.2015.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Timmers L, Van Heuverswyn F, De Wilde H, Jordaens L. Evaluating current implantable cardioverter defibrillator implantation procedures: can common complications be minimised? Expert Rev Cardiovasc Ther 2016; 14:579-89. [DOI: 10.1586/14779072.2016.1144471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Bielefeldt K. Adverse events of gastric electrical stimulators recorded in the Manufacturer and User Device Experience (MAUDE) Registry. Auton Neurosci 2016; 202:40-44. [PMID: 26850819 DOI: 10.1016/j.autneu.2016.01.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 01/18/2016] [Accepted: 01/25/2016] [Indexed: 12/12/2022]
Abstract
The role of gastric electrical stimulation for patients with refractory symptoms of gastroparesis remains controversial. Open label studies suggest benefit while randomized controlled trials did not demonstrate differences between active and sham intervention. Using a voluntary reporting system of the Federal Drug Administration, we examined the type and frequency of adverse events. METHODS We conducted an electronic search of the Manufacturer and User Device Experience (MAUDE) databank using the keyword 'Enterra' for the time between January of 2001 and October of 2015. We abstracted information about the year of stimulator implantation, the year and type of adverse effect, the resulting intervention and outcome if available. RESULTS A total of 1587 entries described adverse effects related the GES. Only 36 of the reports listed perioperative complications. The vast majority described problems that could be classified as patient concerns, local complications, or system failure. The most common problem related lack or loss of efficacy, followed by pain or complications affecting the pocket site. A subset of 801 reports provided information about the time between system implant and registration of concerns, which gradually declined over time. More than one third (35.7%) of the reported adverse events prompted surgical correction. CONCLUSION The number of voluntarily reported adverse events and the high likelihood of repeated surgical interventions clearly demonstrate the potential downside of gastric electrical stimulation. Physicians considering this intervention will need to carefully weigh these risks and include this information when counseling or consenting patients.
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Affiliation(s)
- Klaus Bielefeldt
- University of Pittsburgh Medical Center, Division of Gastroenterology, 200 Lothrop St., Pittsburgh, PA 15213, United States.
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40
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Inacio RC, Klautau GB, Murça MAS, da Silva CB, Nigro S, Rivetti LA, Pereira WL, Salles MJC. Microbial diagnosis of infection and colonization of cardiac implantable electronic devices by use of sonication. Int J Infect Dis 2015. [PMID: 26216762 DOI: 10.1016/j.ijid.2015.07.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES The clinical utility of sonication as an adjunctive diagnostic tool for the microbial diagnosis of cardiac implantable device-associated infections (CIDAIs) was investigated. METHODS The implants of 83 subjects were investigated, 15 with a CIDAI and 68 without a clinical infection. Clinical data were analyzed prospectively and sonication fluid cultures (83 patients, 100%) and traditional cultures (31 patients, 37.4%) were performed RESULTS Generator pocket infection and device-related endocarditis were found in 13 (86.7%) and four (26.7%) subjects, respectively. The mean numbers of previous technical complications and infections were higher in the infected patients compared to the non-infected patients (8 vs. 1, p<0.001; 2 vs. 0, p<0.031, respectively). The sensitivity and specificity for detecting CIDAI was 73.3% (11/15) and 48.5% (33/68) for sonication fluid culture, and 26.7% (4/15) and 100% (16/16) for traditional culture (p<0.001), respectively. A higher number of organisms were identified by sonication fluid than by tissue culture (58 vs. 4 specimens; p<0.001). The most frequent organisms cultured were Gram-positive cocci (66.1%), mainly coagulase-negative staphylococci (35.5%). Thirty-five (51.5%) non-infected subjects were considered colonized due to the positive identification of organisms exclusively through sonication fluid culture. CONCLUSIONS Sonication fluid culture from the removed cardiac implants has the potential to improve the microbiological diagnosis of CIDAIs.
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Affiliation(s)
| | - Giselle Burlamaqui Klautau
- Department of Internal Medicine, Division of Infectious Diseases, Santa Casa de São Paulo School of Medical Sciences, Rua Dr Cesáreo Mota Jr 112, CEP 01303-060, São Paulo, SP, Brazil
| | - Maria Aparecida S Murça
- Department of Laboratory Medicine and Pathology, Division of Infectious Diseases, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | - Cely Barreto da Silva
- Department of Laboratory Medicine and Pathology, Division of Infectious Diseases, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | - Stanley Nigro
- Department of Laboratory Medicine and Pathology, Division of Infectious Diseases, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | - Luiz Antonio Rivetti
- Department of Surgery, Division of Infectious Diseases, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | - Wilson Lopes Pereira
- Department of Surgery, Division of Infectious Diseases, Santa Casa de São Paulo School of Medical Sciences, São Paulo, Brazil
| | - Mauro Jose Costa Salles
- Department of Internal Medicine, Division of Infectious Diseases, Santa Casa de São Paulo School of Medical Sciences, Rua Dr Cesáreo Mota Jr 112, CEP 01303-060, São Paulo, SP, Brazil.
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41
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Lakkireddy D, Pillarisetti J, Atkins D, Biria M, Reddy M, Murray C, Bommana S, Shanberg D, Adabala N, Pimentel R, Dendi R, Emert M, Vacek J, Dawn B, Berenbom L. IMpact of pocKet rEvision on the rate of InfecTion and other CompLications in patients rEquiring pocket mAnipulation for generator replacement and/or lead replacement or revisioN (MAKE IT CLEAN): A prospective randomized study. Heart Rhythm 2015; 12:950-6. [DOI: 10.1016/j.hrthm.2015.01.035] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Indexed: 11/26/2022]
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Unsworth JD, Zaidi A, Hargreaves MR. Increased late complex device infections are determined by cardiac resynchronization therapy-defibrillator infection. Europace 2015; 17:1708-11. [DOI: 10.1093/europace/euv074] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 02/26/2015] [Indexed: 11/13/2022] Open
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43
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Kennergren C. Management of Cardiovascular Implantable Electronic Devices Infections in High-Risk Patients. Arrhythm Electrophysiol Rev 2015; 4:53-7. [PMID: 26835101 DOI: 10.15420/aer.2015.4.1.53] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 02/27/2015] [Indexed: 11/04/2022] Open
Abstract
The incidence of infection following implantation of cardiovascular implantable electronic devices (CIEDs) is increasing, as is the number of pulse generator replacements and upgrades. The rate of infections is rising faster than the rate of device implantation, mainly due to the increasing age and number of comorbidities of patients receiving the devices. Patients with a CIED infection usually require hospitalisation, multiple consultations, prolonged intravenous antibiotics and, in the majority of cases, CIED explantation and replacement. A significant proportion die of their infection. CIED infection therefore represents a substantial health and economic burden, and management of infections is critical. Numerous risk factors have been identified including host, procedure and device-related factors. Established strategies for preventing CIED infections include intravenous antibiotics and aseptic techniques. The TYRX™ Absorbable Antibacterial Envelope offers potential as an effective method to reduce CIED infections. Several studies have found a statistically significant association between antibacterial envelope use and reduced incidence of CIED infection in high-risk patients. A prospective, randomised trial to further evaluate this potentially important strategy for CIED infection prophylaxis is underway.
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Usefulness of sonication of cardiovascular implantable electronic devices to enhance microbial detection. Am J Cardiol 2015; 115:912-7. [PMID: 25779615 DOI: 10.1016/j.amjcard.2015.01.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 01/06/2015] [Accepted: 01/06/2015] [Indexed: 11/22/2022]
Abstract
The cardiovascular implantable electronic device (CIED) infection rate is rising disproportionately to the rate of device implantation. Identification of microorganisms that cause CIED infections is not always achieved using present laboratory techniques. We conducted a prospective study to determine whether device vortexing-sonication followed by culture of the resulting sonicate fluid would enhance microbial detection compared with traditional swab or pocket tissue cultures. Forty-two subjects with noninfected and 35 with infected CIEDs were prospectively enrolled over 12 months. One swab each from the device pocket and device surface, pocket tissue, and the CIED were collected from each patient. Swabs and tissues were cultured using routine methods. The CIED was processed in Ringer's solution using vortexing-sonication and the resultant fluid semiquantitatively cultured. Tissue and swab growth was considered significant when colonies grew on ≥2 quadrants of the culture plate and device was considered significant when ≥20 colonies were isolated from 10 ml of sonicate fluid. In noninfected group, 5% of sonicate fluids yielded significant bacterial growth, compared with 5% of tissue cultures (p = 1.00) and 2% of both pocket and device swab cultures (p = 0.317 each). In infected group, significant bacterial growth was observed in 54% of sonicate fluids, significantly greater than the sensitivities of pocket swab (20%, p = 0.001), device swab (9%, p <0.001), or tissue (9%, p <0.001) culture. In conclusion, vortexing-sonication of CIEDs with semiquantitative culture of the resultant sonicate fluid results in a significant increase in the sensitivity of culture results, compared with swab or tissue cultures.
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45
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Chu XM, Yu H, Sun XX, An Y, Li B, Li XB. Identification of bacteriology and risk factor analysis of asymptomatic bacterial colonization in pacemaker replacement patients. PLoS One 2015; 10:e0119232. [PMID: 25768661 PMCID: PMC4358962 DOI: 10.1371/journal.pone.0119232] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Accepted: 01/20/2015] [Indexed: 11/24/2022] Open
Abstract
Background Recent researches revealed that asymptomatic bacterial colonization on PMs might be ubiquitous and increase the risk of clinical PM infection. Early diagnosis of patients with asymptomatic bacterial colonization could provide opportunity for targeted preventive measures. Objective The present study explores the incidence of bacterial colonization of generator pockets in pacemaker replacement patients without signs of infection, and to analyze risk factors for asymptomatic bacterial colonization. Methods From June 2011 to December 2013, 118 patients underwent pacemaker replacement or upgrade. Identification of bacteria was carried out by bacterial culture and 16S rRNA sequencing. Clinical risk characteristics were analyzed. Results The total bacterial positive rate was 37.3% (44 cases), and the coagulase-negative Staphylococcus aureus detection rate was the highest. Twenty two (18.6%) patients had positive bacterial culture results, of which 50% had coagulase-negative staphylococcus. The bacterial DNA detection rate was 36.4 % (43 cases). Positive bacterial DNA results from pocket tissues and the surface of the devices were 22.0% and 29.7%, respectively. During follow-up (median, 27.0 months), three patients (6.8%, 3/44) became symptomatic with the same genus of microorganism, S. aureus (n=2) and S. epidermidis (n=1). Multivariable logistic regression analysis showed that history of bacterial infection, use of antibiotics, application of antiplatelet drugs, replacement frequency were independent risk factors for asymptomatic bacterial colonization. Conclusion There was a high incidence of asymptomatic bacterial colonization in pacemaker patients with independent risk factors. Bacterial culture combined genetic testing could improve the detection rate.
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Affiliation(s)
- Xian-Ming Chu
- Department of Cardiology, the Affiliated Hospital of Qingdao University, Qingdao, 266100, China
- * E-mail: (XC); (YA)
| | - Hua Yu
- The Affiliated Cardiovascular Hospital of Qingdao University, Qingdao, 266000, China
| | - Xue-Xia Sun
- Department of Cardiology, the Affiliated Hospital of Qingdao University, Qingdao, 266100, China
| | - Yi An
- Department of Cardiology, the Affiliated Hospital of Qingdao University, Qingdao, 266100, China
- * E-mail: (XC); (YA)
| | - Bing Li
- Department of Biology, Medical College of Qingdao University, Qingdao, 266021, China
| | - Xue-Bin Li
- Department of Cardiac Electrophysiology, Peking University People's Hospital, Beijing, 100044, China
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Machino T, Sekiguchi Y. Positive Pocket Cultures From Cardiac Implantable Electrophysiological Devices Without Infection – Contamination or Colonization? –. Circ J 2015; 79:1680-1. [DOI: 10.1253/circj.cj-15-0645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Takeshi Machino
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba
| | - Yukio Sekiguchi
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba
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47
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Genetic identification and risk factor analysis of asymptomatic bacterial colonization on cardiovascular implantable electronic devices. BIOMED RESEARCH INTERNATIONAL 2014; 2014:725163. [PMID: 25530969 PMCID: PMC4233659 DOI: 10.1155/2014/725163] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 08/17/2014] [Accepted: 08/19/2014] [Indexed: 11/18/2022]
Abstract
Asymptomatic bacterial colonization of cardiovascular implantable electronic devices (CIEDs) is widespread and increases the risk of clinical CIED infection. The aim of the study was to evaluate the incidence of bacterial colonization of generator pockets in patients without signs of infection and to analyze the relationship with clinical infection and risk factors. From June 2011 to December 2012, 78 patients underwent CIED replacement or upgrade. Exclusion criteria included a clinical diagnosis of CIED infection, bacteremia, or infective endocarditis. All patients were examined for evidence of bacterial 16S rDNA on the device and in the surrounding tissues. Infection cases were recorded during follow-up. The bacterial-positive rate was 38.5% (30 cases); the coagulase-negative Staphylococcus detection rate was the highest (9 cases, 11.5%). Positive bacterial DNA results were obtained from pocket tissue in 23.1% of patients (18 cases), and bacterial DNA was detected on the device in 29.5% of patients (23 cases). During follow-up (median 24.6 months), two patients (6.7%, 2/30) became symptomatic with the same species of microorganism, S. aureus and S. epidermidis. Multivariable logistic regression analysis found that the history of bacterial infection, use of antibiotics, application of antiplatelet drugs, replacement frequency, and renal insufficiency were independent risk factors for asymptomatic bacterial colonization.
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48
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Sandoe JAT, Barlow G, Chambers JB, Gammage M, Guleri A, Howard P, Olson E, Perry JD, Prendergast BD, Spry MJ, Steeds RP, Tayebjee MH, Watkin R. Guidelines for the diagnosis, prevention and management of implantable cardiac electronic device infection. Report of a joint Working Party project on behalf of the British Society for Antimicrobial Chemotherapy (BSAC, host organization), British Heart Rhythm Society (BHRS), British Cardiovascular Society (BCS), British Heart Valve Society (BHVS) and British Society for Echocardiography (BSE). J Antimicrob Chemother 2014; 70:325-59. [PMID: 25355810 DOI: 10.1093/jac/dku383] [Citation(s) in RCA: 249] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Infections related to implantable cardiac electronic devices (ICEDs), including pacemakers, implantable cardiac defibrillators and cardiac resynchronization therapy devices, are increasing in incidence in the USA and are likely to increase in the UK, because more devices are being implanted. These devices have both intravascular and extravascular components and infection can involve the generator, device leads and native cardiac structures or various combinations. ICED infections can be life-threatening, particularly when associated with endocardial infection, and all-cause mortality of up to 35% has been reported. Like infective endocarditis, ICED infections can be difficult to diagnose and manage. This guideline aims to (i) improve the quality of care provided to patients with ICEDs, (ii) provide an educational resource for all relevant healthcare professionals, (iii) encourage a multidisciplinary approach to ICED infection management, (iv) promote a standardized approach to the diagnosis, management, surveillance and prevention of ICED infection through pragmatic evidence-rated recommendations, and (v) advise on future research projects/audit. The guideline is intended to assist in the clinical care of patients with suspected or confirmed ICED infection in the UK, to inform local infection prevention and treatment policies and guidelines and to be used in the development of educational and training material by the relevant professional societies. The questions covered by the guideline are presented at the beginning of each section.
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Affiliation(s)
| | - Gavin Barlow
- Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | | | | | | | - Philip Howard
- University of Leeds/Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ewan Olson
- Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | | | - Michael J Spry
- Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - Richard P Steeds
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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49
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Sonication of explanted cardiac implants improves microbial detection in cardiac device infections. J Clin Microbiol 2012. [PMID: 23196364 DOI: 10.1128/jcm.02230-12] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The sonication technique has been shown to be a promising tool for microbiological diagnosis of device-related infections. We evaluated the usefulness of the sonication method for pathogen detection in 80 explanted cardiac components collected from 40 patients, and the results were compared with those of conventional cultures. Forty subjects undergoing cardiac device removal were studied: 20 had cardiac device infection, and 20 subjects underwent elective generator replacement or revision in the absence of infection. Sonication of explanted devices was more sensitive than traditional culture for microbial detection (67% and 50%, respectively; P = 0.0005). The bacterial count detected in sonication fluid culture was significantly higher than that detected in traditional culture in both infected (P = 0.019) and uninfected (P = 0.029) devices. In the infected patients, sonication fluid culture yielded a significantly higher rate of pathogen detection in explanted electrodes than traditional culture (65% versus 45%; P = 0.02), while no differences were found in the generators. Ten strains were detected only through sonication fluid culture: 6 Staphylococcus epidermidis strains, 1 Staphylococcus hominis strain, 2 Corynebacterium striatum strains, and 1 Brevundimonas sp. Neither the type nor the duration of antimicrobial therapy before device removal had an effect on the diagnostic performance of sonication fluid culture (P = 0.75 and P = 0.56, respectively). In the patients without infection, sonication fluid culture was positive in 8 cases (40%), whereas conventional culture was positive in only 4 (20%). In summary, the sonication technique improves the microbiological diagnosis of explanted cardiac devices.
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Nagpal A, Baddour LM, Sohail MR. Microbiology and Pathogenesis of Cardiovascular Implantable Electronic Device Infections. Circ Arrhythm Electrophysiol 2012; 5:433-41. [DOI: 10.1161/circep.111.962753] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Avish Nagpal
- From the Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Larry M. Baddour
- From the Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Muhammad R. Sohail
- From the Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN
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