Waseem Ahmad MD

Are cardiovascular implantable
electronic devices Infections risen out of
proportion as compare to overall
increase in their use ?
 Yes
 No

Cardiovascular implantable electronic
devices (CIED) include permanent
pacemakers (PPMs), implantable
cardioverter-defibrillators (ICDs), and left
ventricular assist devices (LVADs).
 There
is a high incidence of cardiovascular
disease among the United States’ population
and subsequently, an increasing number of
patients undergoing placement of CIEDs to
improve quality of life and survival.



When ICDs were first used in the 1980s, these devices were
generally implanted by cardiac surgeons with the assistance
of cardiologists. At that time, procedures were quite
complex because the large generators required
implantation within the abdomen and tunneled leads were
placed epicardially via thoracotomy.
Infection rates using this approach were reported as high as
17%.
Over time, the generator size has decreased substantially,
facilitating implantation in the pectoral region and insertion
of trans venous leads through the subclavian vein in a single
procedure significantly decrease the infection rate
 Infectious
complications of cardio vascular
implantable electronic devices (CIED) have
risen out of proportion to overall increases
in use.
 The
management of CIED infections is
clinically challenging and it results in
substantial morbidity and mortality for
patients.
NHDS estimated that 4.1% to 5.8% of CIED
devices became infected between 2004 and
2006.
 A study that reviewed NHDS data reported a 57%
increase in infections but only a 12% increase in
devices implanted between 2004 and 2006 .


Although the exact reasons for this increase
remain unknown, more device use among older
patients and others with comorbid conditions
may provide a partial explanation

Number of device-related infections related to the number
of new implanted devices over time in the United States.
(purple line) Number of infected implanted cardiac devices
by year of hospitalization normalized to the year 1996. (blue
line) Proportional increase in the number of devices
implanted normalized to the year 1996.
1.Heart failure
2.Diabetes
3.Renal insufficiency
4.Anticoagulation
5.chronic obstructive pulmonary disease
6.corticosteroid use,
7.dvanced age (>60 year)


(Rising rates of cardiac rhythm management device infections in the
United States: 1996 through 2003. J Am Coll Cardiol. 2006)
(implantable cardioverter defibrillator infections: seven years of
diagnostic and therapeutic experience of a single center. Clin Cardiol.
2010)
1.Not using appropriate Antimicrobial
prophylaxis before PPM and ICD
placement
2.The presence of two pacing leads
3.Generator replacement
4. Temporary pacing before implantation
5.Fevers within 24 hours before
implantation.
6.Early reintervention for pocket
hematoma or lead dislodgement.
7.Development of postoperative
complications at the generator pocket.

(Risk factors associated with early- versus late-onset
implantable cardioverter-defibrillator infections. J Interv
Card Electrophysiol. 2011)
1.
Patients with dual chamber systems
developed more infections
2.
ICDs might carry an increased risk
compared with PPM.
 (Permanent
pacemaker and implantable cardioverter
defibrillator infection Arch InternMed 2007
)
 Which
one is the most common organism
related to CIED infections.
 Coagulase
negative Staph
 Staphylococcus aureus
 Gram negative Rods
 Mycobacterium species
 Fugal pathogen


Gram-positive organisms remain the predominant
pathogens associated with CIEDinfection—
specifically coagulase-negative staphylococci (CNS)
or Staphylococcus aureus
A recent Mayo Clinic study examining CIED
infections reported CNS in 41% of patients, S aureus
in 41% of patients, and various gram-negative
bacilli,fungi, and Propionibacterium acnes in the
remainder
 (Infective endocarditis complicatingpermanent pacemaker and
implantable cardioverter-defibrillator infection.Mayo Clin Proc 2008)



Patients with cardiac device infections can be
divided into two broad clinical categories.
The first group has infection limited to the
generator pocket site, with or without associated
bacteremia.
The second group has a primary endovascular
infection with lead vegetations or an infection of
intra cardiac structures (endocarditis)

CIED infections can present with a wide variety
of symptoms and can often pose a diagnostic
challenge for clinicians.
1. localized signs of inflammation at the generator
pocket, such as erythema, warmth, fluctuance,
wound dehiscence, tenderness, purulent drainage,
or erosion of the generator or lead
2.CIED-associated endocarditis by the presence
of lead or valvular vegetations on
echocardiography or by whether the modified
Duke criteria for infective endocarditis are met.
Patients with suspected CIED infection, clinicians should perform
1. two sets of blood cultures,
2. tissue cultures from the generator pocket site,
3. lead tip cultures (when CIED will remove)
Generator pocket cultures identified a causative pathogen
in61%to81%
lead tip cultures were positive in 63.3% to 79%of cases.
Establishing the diagnosis of endocarditis by a positive lead culture
without evidence of vegetation on transesophageal
echocardiography or bacteremia can be misleading and
inappropriately result in an extended duration of antimicrobial
therapy.



Transesophageal echocardiography (TEE) should be
performed when patients are bacteremic, when endocarditis
is suspected because of clinical findings, or when blood
cultures are negative in the setting of recent antibiotic
exposure.
Caution should be exercised in cases of incidental masses
associated with leads found in the absence of clinical
suspicion for infection because many may be thrombotic in
nature.
Clinicians should not rely on transthoracic
echocardiography for ruling out endocarditisbecause of low
sensitivity in comparison to TEE
 Mortality
ranges from 7.4% to 18%with
complete device extraction and from
8.4% to 41% with partial device
extraction or antimicrobial therapy alone.

Contemporary management of and outcomes from cardiac device
related infections. Europace 2010)
1.generator or lead erosion (even without evidence of local
inflammation),
2.Pocket infection
3. valve endocarditis
4. lead endocarditis
Antimicrobials alone or in combination with partial device
removal is associated with unacceptably high relapse rates
and significant mortality
5. A superficial, localized infection of the incision
without involvement of the device pocket is one exception .




Historically, surgical lead removal with a thoracotomy was
considered in patients with vegetation diameters less than 10 mm
or with retained hardware after failed attempts with percutaneous
lead removal.
A recent update on the management on CIED infections and a poll
of an expert panel advocated that percutaneous removal could be
performed safely at high volume centers when lead vegetations
are smaller than 2 cm.
vegetations larger than 2 cm there are limited data on the
appropriateness of percutaneous versus surgical removal. The
decision regarding approach should be individualized
(Update on cardiovascular implantable electronic device
infections and their management: a scientific statement from the
American Heart Association. Circulation 2010)
Damage to the tricuspid valve
2. Subclavian vein laceration
3. Hemothorax
4. Pocket hematoma
5. Fracture of lead tip
1.
Approach to antimicrobial treatment of adults with CIED infection J Am Coll Cardiol 2007
 Based
on recent IDSA guidelines
addressing the management of
methicillin resistant S aureus (MRSA)
infection, patients with SAB in the setting
of a CIED infection are classified as
complicated SAB and they should receive
4 to 6 weeks of antimicrobial Therapy
 One-third
to one-half of patients may not
require a new CIED implantation
 70
y m presented with SAB with a CIED
for three years who do not have clinical
evidence of generator-site infection, lead
vegetation, or valve vegetation .what are
the chances that he has CIED infection
 10%
 25%
 50%
 100%


The management of S aureus bacteremia (SAB)
among patients with a CIED who don ot have clinical
evidence of generator-site infection, lead vegetation,
or valve vegetation remains challenging.
Prospective studies suggest the incidence of CIED
infection may be as high as 45% in patients with SAB.
(Staphylococcus aureus bacteremiain patients with
permanent pacemakers or implantable cardioverterdefibrillators.Circulation 2001)
1.SAB without another identified source.
2.Recurrent SAB
3.Persistent bacteremia (24 hours)
4.Presenceof a prosthetic valve.
5. Presence of an ICD and bacteremia within
3months of device placement

(Staphylococcus aureus bacteremia in patients
with permanent pacemakers or implantable
cardioverter-defibrillators. Circulation 2001)
1.
Only 6% of patients had either definite or possible CIED infection.
2.
No patients seemed to have secondary hematogenous seeding
of the system.
3.
Device extraction in the setting of gram-negative bacteremia is
not recommended without clinical or echocardiographic
evidence of CIED infection unless bacteremia is persistent or
relapses withthout another defined focus of infection

(Update on cardiovascular implantableelectronic device infections
and their management: a scientific statementfrom the American
Heart Association. Circulation 2010)
1.
2.
Antimicrobial prophylaxis reduces the risk
of CIED infection antimicrobial prophylaxis
in the postoperative period is currently not
recommended.
The antibacterial envelope is a polymer
mesh that releases rifampin and
minocycline after implantation. Nearly half
the patients (49%)in this study had at least
three established risk factors for
development of CIED infection, but there
was a low rate of infection (<0.50%)
 1.CIED
infections are an increasing
problem associated with high morbidity
and mortality.
 2.Major risk factors for CIED infection
include renal insufficiency, presence of
indwelling catheters, diabetes mellitus,
and corticosteroid use.
 3.Staphylococcus spp are the most
common pathogen, whereas gramnegative bacteria are rarely implicated.
.
4.Blood cultures, generator pocket tissue
cultures, lead tip cultures, and echocardiography
are key aspects of the diagnostic work-up for
suspected CIED infection.
 5. Complete removal of all hardware is strongly
recommended, along with adjunctive
antimicrobial therapy.


Patient is at extremely high risk of peri
procedural complications or has limited life
expectancy. In such cases, chronic suppressive
antimicrobial treatment may be preferred

Thank You