Bacteraemia after leadless pacemaker implantation

Risk of Cardiac Implantable Electronic Device Infection after Early versus Delayed Lead Repositioning

(1) Background: Early reintervention increases the risk of infection of cardiac implantable electronic devices (CIEDs). Some operators therefore delay lead repositioning in the case of dislocation by weeks; however, there is no evidence to support this practice. The aim of our study was to evaluate the impact of the timing of reoperation on infection risk. (2) Methods: The data from consecutive patients undergoing lead repositioning in two European referral centers were retrospectively analyzed. The odds ratio (OR) of CIED infection in the first year was compared among patients undergoing early (≤1 week) vs. delayed (>1 week to 1 year) reoperation. (3) Results: Out of 249 patients requiring CIED reintervention, 85 patients (34%) underwent an early (median 2 days) and 164 (66%) underwent a delayed lead revision (median 53 days). A total of nine (3.6%) wound/device infections were identified. The risk of infection was numerically lower in the early (1.2%) vs. delayed (4.9%) intervention group yielding no statistically significant difference, even after adjustment for typical risk factors for CIED infection (adjusted OR = 0.264, 95% CI 0.032-2.179, p = 0.216). System explantation/extraction was necessary in seven cases, all being revised in the delayed group. (4) Conclusions: In this bicentric, international study, delayed lead repositioning did not reduce the risk of CIED infection.

Leadless Pacemaker Infection Risk in Patients with Cardiac Implantable Electronic Device Infections: A Case Series and Literature Review

(1) Background: Leadless pacemakers (LPs) have been proposed as a reimplantation strategy in pacing-dependent patients undergoing cardiac implantable electronic device (CIED) extraction for infection. In this study, we analysed the risk of LP infection when this device is implanted before lead extraction. (2) Methods: This was a retrospective study including patients who underwent LP implantation between 2017 and 2022. Patients were divided in two groups according to whether LP was implanted following CIED extraction for infection (Group 1) or other indications (Group 2). The primary aim was to describe the risk of LP infection. (3) Results: We included in this study 49 patients with a median age of 81 [20-94] years, mostly males (36, 73%). In Group 1 patients, 17 cases (85%) showed systemic CIED infections, and 11 (55%) had positive lead cultures. Most Group 1 cases (n = 14, 70%) underwent one stage of LP implantation and CIED extraction. Mortality rate during follow-up was 20% (nine patients). Patients were followed up for a median of 927 [41-1925], days and no cases of definite or suspected LP infections were identified. (4) Conclusions: The risk of LP infection was extremely low. LP appears as a potential option for reimplantation in this setting and should be considered in pacing-dependent patients at a high risk of CIED infection recurrence.

Paradigm Shifts in Cardiac Pacing: Where Have We Been and What Lies Ahead?

The history of cardiac pacing dates back to the 1930s with externalized pacing and has evolved to incorporate transvenous, multi-lead, or even leadless devices. Annual implantation rates of cardiac implantable electronic devices have increased since the introduction of the implantable system, likely related to expanding indications, and increasing global life expectancy and aging demographics. Here, we summarize the relevant literature on cardiac pacing to demonstrate the enormous impact it has had within the field of cardiology. Further, we look forward to the future of cardiac pacing, including conduction system pacing and leadless pacing strategies.

Concomitant leadless pacing in pacemaker-dependent patients undergoing transvenous lead extraction for active infection: Mid-term follow-up

BACKGROUND

The rate of transvenous lead extraction (TLE) due to cardiac implantable electronic device (CIED) infection continues to rise. CIED infections are associated with significant morbidity and mortality. Temporary pacing in patients with active CIED infections after TLE can be challenging. Leadless pacing has emerged as an alternative approach in this patient population.

OBJECTIVE

The purpose of this study was to describe the outcomes of a strategy using concomitant leadless pacemaker implantation and TLE in patients with active infections and ongoing pacing requirements.

METHODS

This study involved all leadless pacemaker implantation procedures performed during TLE between June 2018 and September 2022 in the setting of active infection. Demographic characteristics, procedural details, and clinical outcomes were analyzed.

RESULTS

The study included 86 patients with indications for ongoing pacing, 60 (70%) men with mean age 77.4 ± 10.5 years, who underwent TLE and concomitant leadless pacemaker implantation in the setting of active infection. There were no procedure-related complications. Sixty-five patients (76%) had evidence of bacteremia, 80% of whom were discharged to complete their antimicrobial treatment. During a median follow-up of 163 days (interquartile range 57-403 days), there were no recurrent infections. Of the 25 deaths (29%) during the study period, 22 (88%) were unrelated to the initial infection. Nine deceased patients (36%) had methicillin-resistant Staphylococcus aureus or Candida infections, 3 of whom had persistent infection despite TLE.

CONCLUSION

Leadless pacing is a safe and efficacious approach for the management of patients with pacing requirements that undergo CIED extraction in the setting of active infection.

Review article: diagnosis, pathophysiology and management of atrial fibrillation in cirrhosis and portal hypertension

BACKGROUND

Atrial fibrillation (AF) is the most common arrhythmia and its management in cirrhosis can be challenging due to the altered hepatic metabolism of medications and increased risk of bleeding.

AIMS

To provide a comprehensive overview of the diagnosis, pathophysiology and management of AF in patients with cirrhosis from both a cardiology and a hepatology perspective.

METHODS

An extensive literature search was performed using the terms 'atrial fibrillation' and 'cirrhosis'. Guideline documents and consensus statements were explored.

RESULTS

The prevalence of AF in patients with cirrhosis ranges between 6.6% and 14.2%, while the incidence of new-onset AF in the post-operative period after liver transplant ranged between 6.8% and 10.2%. AF in patients with cirrhosis is associated with adverse outcomes in both pre-transplant and post-transplant settings, including an increased risk of stroke when compared to the general population. We review the pathogenesis of AF in general and in cirrhosis. This review also provides guidance on the management of AF, including the use of anticoagulation and rate versus rhythm control. In the absence of strict contraindications, all patients with cirrhosis and AF should be anticoagulated. The use of DOACs is preferred over vitamin K antagonists. In patients with a high bleeding risk, a DOAC with an approved antidote may be preferred.

CONCLUSIONS

Atrial fibrillation is increased in patients with cirrhosis. AF management requires careful consideration of treatment options. Since patients with cirrhosis were excluded from all major randomised clinical trials, dedicated research on the pathophysiology and management of AF in cirrhosis is needed.

Clinical Updates in Cardiac Pacing—The Future Is Bright

The history of cardiac pacing has been defined by many innovation milestones starting in the early 1960s [...]

Cardiac Implantable Electronic Devices Infection Assessment, Diagnosis and Management: A Review of the Literature

The use of increasingly complex cardiac implantable electronic devices (CIEDs) has increased exponentially in recent years. One of the most serious complications in terms of mortality, morbidity and financial burden is represented by infections involving these devices. They may affect only the generator pocket or be generalised with lead-related endocarditis. Modifiable and non-modifiable risk factors have been identified and they can be associated with patient or procedure characteristics or with the type of CIED. Pocket and systemic infections require a precise evaluation and a specialised treatment which in most cases involves the removal of all the components of the device and a personalised antimicrobial therapy. CIED retention is usually limited to cases where infection is unlikely or is limited to the skin incision site. Optimal re-implantation timing depends on the type of infection and on the results of microbiological tests. Preventive strategies, in the end, include antibiotic prophylaxis before CIED implantation, the possibility to use antibacterial envelopes and the prevention of hematomas. The aim of this review is to investigate the pathogenesis, stratification, diagnostic tools and management of CIED infections.

OUTCOMES OF LEADLESS PACEMAKER IMPLANTATION IN PATIENTS WITH MECHANICAL HEART VALVES

INTRODUCTION

Device infections constitute a major complication of transvenous pacemakers. Mechanical heart valves (MHV) increase the risk of infective endocarditis (IE) and pacemaker infection, requiring lifelong vitamin K-antagonists (VKA), which may affect patient management. Leadless pacemakers (LP) are associated with low infection rates, posing an attractive option in MHV patients requiring permanent pacing.This study describes outcomes following LP implantation in patients with MHV.

METHODS

This is a multicenter, observational, retrospective study including consecutive patients implanted with an LP at 5 centers between June 2015 and January 2020.Procedural outcomes, antithrombotic management, complications, performance during follow-up and episodes of bacteremia and IE were compared between patients with and without an MHV (MHV and non-MHV groups).

RESULTS

Four hundred fifty-nine patients were included (74 in the MHV group, 16.1%, and 385 in the non-MHV group, 83.9%).Procedural outcomes and acute electrical performance were comparable between groups.Vascular complications and cardiac perforation occurred in 2.7 vs. 2.3% (p=1) and 0% vs. 0.8% (p=1) in the MHV group and non-MHV group.One case of IE occurred in the MHV group and 2 in the non-MHV group.In MHV patients, uninterrupted VKA was used in 83.8 %, whereas 16.2 % were heparin-bridged.Vascular complication or tamponade occurred in 1(8.3 %) MHV heparin-bridged patient vs. 1 (1.6 %) MHV uninterrupted VKA patient (p=0.3).

CONCLUSION

LP implantation outcomes in MHV patients are comparable to the general LP population.Device-related infections are rare following LP implantation, including in patients with MHV.In the MHV group, periprocedural anticoagulation management was not associated with significantly different rates of tamponade or vascular complication. This article is protected by copyright. All rights reserved.

18F-FDG PET/CT in cardiovascular infection and inflammation

The diagnosis of cardiovascular infection and inflammation by [¹⁸F]FDG PET/CT in Nuclear Cardiology is of growing interest, because with respect to echocardiography this technique has improved the certainty in the diagnosis of infective endocarditis in patients with prosthetic valves, the increasing number of patients with implantable cardiac devices because of the progressive ageing of the population, as well as in patients with suspected large vessel vasculitis. All are serious clinical situations which require correct diagnosis and appropriate treatment as soon as possible, because they can cause severe complications, high mortality and also increased health care costs. We review the use of [¹⁸F]FDG PET/CT in cardiovascular infection and inflammation, including the clinical point of view and the contribution of other image modalities. We focus on the appropriate methodology for this exploration, patient preparation, image acquisition and correct interpretation and the quantification possibilities, defining the specific characteristics of the diagnosis in patients with prosthetic valves, implantable cardiac devices and large vessel vasculitis in the initial diagnosis as well as during follow-up to assess treatment response. We analyze the possible causes of false positive and false negative results and emphasize the special value of a multidisciplinary team for optimal management of these patients.

Tips and Tricks for Safe Retrieval of Tine-based Leadless Pacemakers

As leadless pacing (LP) use is expected to increase, it becomes increasingly essential that operators become familiar with the tools and techniques needed to retrieve an LP successfully. The purpose of this review is to describe a stepwise approach for the successful retrieval of tine-based LP devices, including ways to minimize complications.

Ventricular electrical storm after Micra™ leadless pacemaker implant

Peri- and post-procedural ventricular tachycardia (VT) is a rare complication after leadless pacemaker implantation and requires an individualized approach. In this case report we describe the management of VT in a patient with subendocardial scarring due to prior coronary artery disease who presented with monomorphic VT the day after implant. The etiology was found to be related to the novel ventricular activation wavefront by ventricular pacing which induced a reentrant circuit dependent on pre-existing myocardial substrate. Invasive electrophysiologic study and ablation is a safe and successful treatment strategy in selected patients with evidence of myocardial scarring.