New Insights into Predictors of Cardiac Implantable Electronic Device Infection

Outcomes in cardiac implantable electronic device-related infective endocarditis: a systematic review of current literature

Aim: Cardiac implantable electronic device infective endocarditis is a serious infection with poor prognosis. Materials & methods: The systematic review of the literature was conducted using searches from the various databases. We included studies published between January 2010 and June 2021. Results: A total of 35 articles met the inclusion criteria. Patients were approximately 70 years old and an average of 71.2% of patients were male. The most common presenting feature was a fever. The modified Duke criteria was used to aid diagnosis. Management entailed extraction of the cardiac implantable electronic device in 80.5% of the studies. The overall mortality rates ranged from 4 to 36%. The most frequently isolated organism was Staphylococcus aureus. Conclusion: Cardiac implantable electronic device infective endocarditis needs timely diagnosis and effective management for promising outcomes.

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.

Rate of Cardiovascular Implantable Electronic Device-Related Infection at a Tertiary Hospital in Saudi Arabia: A Retrospective Cohort Study

Introduction

Cardiovascular implantable electronic devices (CIEDs) are long-term cardiac treatments that address a variety of cardiac diseases. In the recent years, a steady growth has been noticed in CIEDs, mainly due to expanding indications for their usage. Possible device-related infection, whether pocket or systemic, which leads to high morbidity and mortality, is one of the most worrying complications. In addition, there are limited studies conducted on the topic of CIED infection rate and their clinical presentation both regionally and locally.

Methods

In this retrospective cohort study, we reviewed the medical records of all patients with CIEDs who presented to our medical center (implanted, followed up, or referred to our hospital) between January 2016 and January 2019.The medical records were extracted from the BestCare electronic medical records system (ezCaretech Co, Seoul, Korea). All consecutive patients were included as we had no exclusion criteria.

Results

During the three years of the study period, a total of 612 patients with CIEDs were identified at our medical center. Among this cohort, 436 subjects (71.2%) were male and 176 (28.8%) were female. Thirty-four patients experienced device-related infections from among the total patient population (n = 612) who presented with CIEDs between January 2016 and January 2019, for a total rate of 5.6%. Of the infected patients, 29 (85%) presented with local infections and five (15%) presented with systemic infections.

Conclusion

The infection rate of 5.6% observed in this study was higher than expected. Therefore, we conclude that action should be taken to reduce infection rates at our medical center to at least that seen in prior studies or below that, if possible. Moreover, we found that CIED infections were often caused by Staphylococcus species and commonly affected the elderly and patients with chronic diseases such as diabetes and hypertension. Most of the identified cases were local infections, although systemic infections were common in those with renal disease. Further studies are needed to control the risk factors and to better understand the role of antibiotics, antiseptic prophylaxis, and other methods in avoiding CIED infection and associated complications.

Evaluation of a novel mechanical compression device for hematoma prevention and wound cosmesis after CIED implantation

BACKGROUND

An important complication of cardiac implantable electronic devices (CIED) is the development of hematoma and device infection.

OBJECTIVE

We aimed to evaluate a novel mechanical compression device for hematoma prevention and cosmetic outcomes following CIED.

METHODS

An open, prospective, randomized, single-center clinical trial was performed in patients undergoing CIED implantation. Patients were randomized to receive a novel mechanical compression device (PressRite, PR) or to receive the standard of care post device implantation. Skin pliability was measured with a calibrated durometer; the surgical site was evaluated using the Manchester Scar Scale (MSS) by a blinded plastic surgeon and the Patient and Observer Scar Scale (POSAS). Performance PR was assessed through pressure measurements, standardized scar scales and tolerability.

RESULTS

From the total of 114 patients evaluated for enrollment, 105 patients were eligible for analysis. Fifty-one patients were randomized to management group (PR) and 54 to the control group. No patients required early removal or experienced adverse effects from PR application. There were 11 hematomas (14.8% vs. 5.9% in the control and PR group respectively, p = NS). The control group had higher post procedure durometer readings in the surgical site when compared with the PR group (7.50 ± 3.45 vs. 5.37 ± 2.78; p = <0.01). There were lower MSS scores in the PR group after 2 weeks (p = 0.03).

CONCLUSION

We have demonstrated the safety of PR application and removal. In addition, PR appears to lower post-operative skin pliability, which could improve wound healing. This article is protected by copyright. All rights reserved.

Implantable Cardiac Device Infections Prevalence: Diagnostic and Therapeutic Implications

Background:  It has been demonstrated that the use of cardiac implanted electronic devices (CIED) improve mortality and survivability in a variety of patient populations. Nevertheless, CIED related infection is a serious complication characterized by a high rate of mortality and morbidity. Objectives: To evaluate the prevalence of CIED related infections, risk factors, clinical and demographic characteristics, causative organisms, and the management and outcome of patients presented in the Critical Care Department, Cairo University. Methods: A retrospective analysis was conducted in 1871 individuals who had been implanted with a cardiac device with a total number of devices of 1968 and 2270 procedures performed from January 2007 to December 2017. Results: 59 infectious episodes were identified with an estimated incidence of 2.99% of inserted devices and 2.6% of total procedures.  The infection rate was considerably higher in patients with multiple procedures than those who had a single procedure (9.27% vs. 1.18%; P<0.001). The individuals with a dual-chamber implantable cardiac defibrillator (ICD) and cardiac resynchronization therapy devices (CRTD) had the highest infection rate of 6.25% & 6.85%, respectively. The rate of pocket infection (PI) and CIED related endocarditis (CDE) was 1.54% & 1.06% of total devices respectively.  Numerous risk factors have been found; the most significant of those are diabetes mellitus, recurrent procedures, the device's complexity, and the existence of more than one lead. Gram-positive cocci were the most isolated organisms in all positive cultures (69.23%). Echocardiography revealed lead vegetations and valvular vegetations in 22 patients and 2 patients respectively.  In 53 cases (89.83%), the devices were removed; in 41 cases, the entire system was removed; and in 12 cases, only the generator was removed. The mortality rate was found to be 10.17%, having a considerably higher prevalence in CDE individuals than in pocket infection individuals (20.83% vs. 2.86%; P=0.025). Conclusion: In our center, while the rate of CIED implantation continues to increase, the incidence rate of CIED-related infection continues to decline. Until now, the infection burden associated with secondary intervention is still significantly high.  The management strategy of selection is to eliminate the entire system for patients presented with infection especially those with CDE. However, the mortality rate is still high.

Infection of cardiac prosthetic valves and implantable electronic devices: early diagnosis and treatment

There has been a recent rise in the use of implantable cardiac devices, mostly valves but also electronic ones, such as pacemakers, and implantable defibrillators. The increasing use of these devices had as a consequence the raised incidence of endocarditis, an infrequent but morbid complication of these procedures. Thus, early diagnosis of the implantable cardiac devices related infection and endocarditis became pivotal for appropriate management. For diagnostic purposes, the modified Duke criteria are widely used, which are based on clinical and imaging findings, in addition to serological analyses and blood cultures. 18F-fluoro-2-deoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) is a recently employed method in order to improve the early diagnosis of endocarditis as well as infection of the implantable device. It is likely, that combining the modified Duke criteria with the FDG PET/CT, will increase the sensitivity and specificity of diagnosis and will guide the treating physician to an early and appropriate management.

Postimplantation pocket hematoma increases risk of cardiac implantable electronic device infection: A meta-analysis

INTRODUCTION

 Several studies have shown an inconsistent relationship between postimplantation pocket hematoma and cardiac implantable electronic device (CIED) infection. In this study, we performed a systematic review and meta-analysis to explore the effect of postimplantation hematoma and the risk of CIED infection.

METHODS

 We searched the databases of MEDLINE and EMBASE from inception to March 2020. Included studies were cohort studies, case-control studies, cross-sectional studies, and randomized controlled trials that reported incidence of postimplantation pocket hematoma and CIED infection during the follow-up period. CIED infection was defined as either a device-related local or systemic infection. Data from each study were combined using the random effects, generic inverse variance method of Der Simonian and Laird to calculate odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Fourteen studies were included in final analysis, involving a total of 28 319 participants. In random-effect model, we found that postimplantation pocket hematoma significantly increases the risk of overall CIED infection (OR = 6.30, 95% CI: 3.87-10.24, I 2 = 49.3%). There was no publication bias observed in the funnel plot as well as no small-study effect observed in Egger's test.

CONCLUSIONS

Our meta-analysis demonstrated that postimplantation pocket hematoma significantly increases the risk of CIED infection. Precaution should be taken during device implantation to reduce postimplantation hematoma and subsequent CIED infection.

Antibiotic Prophylaxis and Treatment in Early Cardiac Implantable Electronic Devices Infection

Background

Cardiac implantable electronic devices - PM, ICD, and CRTs- are well-proven life-sustaining and the ultimate destination for many heart conditions. Based on scientific evidence, there is a worldwide incremental increase in CIED implantations numbers.

Objective

Early infection of cardiac implantable electronic devices (CIED)- pacemaker (PM), implantable cardioverter-defibrillator (ICD), and cardiac resynchronization therapy (CRT)- is a growing health challenge. We examined the effectiveness of antibiotic prophylaxis and treatment of early infection of CIED in a single center.

Methods

This is a retrospective, single-center observational study. Data were collected from patients' records from July 2017-July, 2019. All Patients received intravenous ceftriaxone 2gm before incision, Gentamicin 120mg pocket irrigation, and oral Amoxicillin/Clavulanate for 5 days post-implantation.

Results

A 639 consecutive CIED implantations - PM (n=474, mean age, 64yr, female=49%), ICD (n=106, mean age 56yr, female=17%) and CRT (n=59, mean age, 54yr, female=20%)- were performed over 3years. The incidence of early infection was 1.9% (12 cases), female=41%. PM=5/474, ICD=5/106, and CRT=2/59. Three out of the 12 patients had total device explant due to pocket abscess; one PM had a generator changed; one ICD who had a pneumothorax, and the third one had reimplantation after ICD lead perforation. Nine cases were managed conservatively using saline dressing and oral Amoxicillin/Clavulanate, 3/9 patients developed a hematoma, 4/9 patients developed purulent suture line infection. None of them had infection recurrence on three months follow up.

Conclusion

Early infection of CIED is a rare complication with multiple predisposing factors. Our protocol is reassurance and prompt initiation of management protocol to prevent and treat this issue's sequences.

Current strategies to minimize postoperative hematoma formation in patients undergoing cardiac implantable electronic device implantation: A review

There are an increasing number of cardiac electronic device implants and generator changes with a longer patient life expectancy along with concomitant increase in antiplatelet and anticoagulant regimens, which can increase the incidence of pocket hematomas. We have conducted an in-depth analysis on the relevant literature, which is rife with varying definition of hematomas, on ways to reduce pocket hematomas. We have analyzed studies on periprocedural medication management, intraprocedural use of prohemostatic agents, and postprocedure role of compression devices.

Antibiotic envelope is associated with reduction in cardiac implantable electronic devices infections especially for high-power device-Systematic review and meta-analysis

BACKGROUND

Infections after cardiac implantable electronic device (CIED) placement are associated with significant morbidity and mortality. The incidence of CIED is increasing overtime despite the optimal use of antimicrobial agents. This systematic review and meta-analysis will address the latest evidence on the use of AE to mitigate the risk of CIED infection, and which subset of patients will they benefit the most.

METHODS

We performed a comprehensive search on topics that assesses antibiotic envelope and implantable cardiac electronic device up until August 2019.

RESULTS

There were a total of 32,329 subjects from six studies. Antibiotic envelope was associated with a lower risk of major infection with OR 0.42 [0.19, 0.97], P = .04; I2: 58% and HR 0.52 [0.32, 0.85], P = .009; I2: 80%. Upon sensitivity analysis by removing a study, the OR became 0.40 [0.27, 0.59], P < .001; I2: 46%. Subgroup analysis for 12 months' infection was OR 0.65 [0.43, 0.99], P = .04; I2: 49%. Meta-analysis of propensity-matched cohort showed a reduced risk of infection with AE (OR of 0.14 [0.05, 0.41], P < .001; I2:0%). Mortality was similar in both AE and control groups. Antibiotic envelope reduced the incidence of infection in patients receiving high-power device (OR 0.44 [0.27, 0.73], P = .001; I2:0%) but not low-power device.

CONCLUSION

Antibiotic envelope (TYRX) was found to be safe and effective in reducing the risk of major infections in high-risk patients receiving CIED implantation, especially in those receiving high-power CIED.

Strategies to Prevent Cardiac Implantable Electronic Device Infection

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.

Early and Late Effects of Cardiac Resynchronization Therapy in Adult Congenital Heart Disease

Background

There are limited data about cardiac resynchronization therapy (CRT) in adult congenital heart disease. We aimed to assess early and late outcomes of CRT among patients with adult congenital heart disease.

Methods and Results

We retrospectively studied 54 patients with adult congenital heart disease (median age, 46 years; range, 18–73 years; 74% men) who received CRT implantation (biventricular paced >90%) between 2004 and 2017. Clinical and echocardiographic data were analyzed at baseline and early (mean±SD: 1.8±0.8 years) and late (4.7±0.8 years) follow‐up after CRT. Compared with baseline, CRT was associated with significant improvement at early follow‐up in New York Heart Association functional class, QRS duration, and cardiothoracic ratio (P<0.05 for all); improvement in New York Heart Association class was sustained at late follow‐up. Among patients with a systemic left ventricle (LV; n=39), there was significant increase in LV ejection fraction and reduction in LV end‐systolic volume at early and late follow‐up (P<0.05 for both). For patients with a systemic right ventricle (n=15), there was a significant early but not late reduction in systemic right ventricular basal and longitudinal diameters. Eleven patients died, and 2 had heart transplantation unrelated to systemic ventricular morphological characteristics. Thirty‐five patients (65%) responded positively to CRT, but only baseline QRS duration was predictive of a positive response.

Conclusions

CRT results in sustained improvement in functional class, systemic LV size, and function. Patients with a systemic LV and prolonged QRS duration, independent of QRS morphological characteristics, were most likely to respond to CRT.

Device infections in implantable cardioverter defibrillators versus permanent pacemakers: A systematic review and meta-analysis

INTRODUCTION

Recent studies suggest that implantable cardioverter defibrillators (ICDs) are associated with increased risk of cardiac implantable electronic device (CIED) infections when compared with permanent pacemakers (PPMs). However, there were controversies among studies. In this study we performed a systematic review and meta-analysis to explore the risk of device infection in ICD versus PPM.

METHODS

We searched the databases of MEDLINE and EMBASE from inception to January 2019. Data from each study were combined using the random-effects, generic inverse variance method of Der Simonian and Laird to calculate odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Twenty-seven studies involving 202 323 CIEDs (36 782 ICDs and 165 541 PPMs) were included. Infections occurred from 9 days to 6 years postoperatively. When compared with PPM, ICD had a significantly higher risk of device infection in overall analysis (OR = 1.62, 95% CI: 1.29-2.04). The risk was seen in subgroups such as single chamber or dual chamber device (OR = 1.57, 95% CI: 1.18-2.09), de novo implantation (OR = 1.62, 95% CI: 1.29-2.69), revision implantation (OR = 1.63, 95% CI: 1.24-2.13), and cardiac resynchronization therapy (CRT) (OR = 1.75, 95% CI: 1.18-2.60). CRT-defibrillator increased risk of infection over CRT-pacemaker in revision implantation (OR = 1.81, 95% CI: 1.20-2.74) but not in de novo implantation (OR = 1.07, 95% CI: 0.23-4.88). The increased risk of infection among defibrillator was higher in CRT compared to non-CRT but not significant (P = 0.654).

CONCLUSIONS

Our meta-analysis demonstrates a statistically significant increased risk of device infection in CIED patients who received ICD when compared to PPM.

Subpectoral pacemaker implantation under tumescent local analgesia

Tumescent local analgesia (TLA) is an anesthetic technique used for inducing local analgesia over large areas and is rarely used in cardiothoracic surgery. An 83-year-old, extremely thin woman was hospitalized with sick sinus syndrome, requiring pacemaker implantation. We chose a subpectoral mode of implantation to prevent skin complications. General anesthesia was deemed risky due to the history of chronic pulmonary disease; therefore, the operation was successfully performed under TLA. Moreover, TLA helped introduce a subpectoral pocket for implanting the pacemaker with minimal trauma and bleeding. The analgesia was sufficient, with minimal postoperative pain, and required no additional sedatives and analgesics. The patient was discharged without any complications.

Postoperative antibiotic prophylaxis in the prevention of cardiac implantable electronic device infection

BACKGROUND

The aim of the present study was to determine whether postprocedural antibiotic reduces the risk of infection related to the cardiac implantable electronic device (CIED) implantations.

METHODS

The present investigation is a randomized, prospective, single-blinded controlled trial. All consecutive patients who presented for new CIED implantation, generator replacement, or upgrade were randomized into the following three groups: (A) no antibiotic, (B) intravenous (IV) antibiotic for 1 day, (C) 1 day IV plus 7 days oral antibiotic. Follow-up was performed on 10-12 days; 1, 3, 6 months; and then every 6 months for 2 years. The primary endpoint was any evidence of infection at the generator pocket or systemic infection related to the procedure at short-term (6-month) and long-term (2-year) follow-ups.

RESULTS

Of the 450 patients (72 patients with cardiac resynchronization device) included in the study, the primary endpoint of short-term infection was reached in one patient (0.2%) in group A and no patients in groups B and C. The endpoint of long-term infection was reached in nine patients (2%) with equal frequency between three randomized groups (three patients in each group). On multivariable analysis, the only independent predictor of infection was defibrillator implantation (odds ratio, 8.5; 95% confidence interval, 1.6-45).

CONCLUSIONS

The results of this prospective study showed no benefit for the postoperative antibiotic for the prevention of CIED infection.