Risk factors associated with early- versus late-onset implantable cardioverter-defibrillator infections

Unravelling staphylococcal small-colony variants in cardiac implantable electronic device infections: clinical characteristics, management, and genomic insights

Objectives

Staphylococcal small-colony variants (SCVs) are common in cardiac implantable electronic device (CIED) infections. This is the first retrospective and multi-case study on CIED infections due to staphylococcal SCVs, aiming to provide a theoretical basis for the clinical management of CIED and device-related infections caused by staphylococcal SCVs.

Methods

Ninety patients with culture positive CIED infections were enrolled between 2021 and 2022. We compared the demographic and clinical characteristics of patients with and without SCVs and performed genomic studies on SCVs isolates.

Results

Compared to patients without SCVs, those with SCVs had a longer primary pacemaker implantation time and were more likely to have a history of device replacement and infection. They showed upregulated inflammatory indicators, especially higher NEUT% (52.6 vs. 26.8%, P = 0.032) and they had longer hospital stays (median 13 vs. 12 days, P = 0.012). Comparative genomics analysis was performed on Staphylococcus epidermidis wild-type and SCVs. Some genes were identified, including aap, genes encoding adhesin, CHAP domain-containing protein, LPXTG cell wall anchor domain-containing protein, and YSIRK-type signal peptide-containing protein.

Conclusion

Staphylococcal SCVs affect the clinical characteristics of CIED infections. The process of staphylococcal SCVs adherence, biofilm formation, and interaction with neutrophils play a vital role.

Physician antibiotic hydration preferences for biologic antibacterial envelopes during cardiac implantable device procedures

Background

Cardiac implantable electronic device (CIED) infection is a potentially serious complication of CIED procedures. Infection risk mitigation includes using guideline-recommended pre-operative intravenous antibacterial prophylaxis (IV ABX). The use of antibiotic-eluting CIED envelopes has also been shown to reduce infection risk. The relationship between and potential benefits associated with guideline-recommended IV ABX in combination with antibacterial envelopes have not been characterized.

Methods

Biologic envelopes made from non-crosslinked extracellular matrix (ECM) were implanted into 1,102 patients receiving CIEDs. The implanting physician decided patient selection for using a biologic envelope and envelope hydration solution. Observational data was analyzed on IV ABX utilization rates, antibacterial envelope usage, and infection outcomes.

Results

Overall compliance with IV ABX was 96.6%, and most patients received a biologic envelope hydrated in antibiotics (77.1%). After a mean follow-up of 223 days, infection rates were higher for sites using IV ABX <80% of the time vs. sites using ≥80% (5.6% vs. 0.8%, p = 0.008). Physicians demonstrated preference for hydration solutions containing gentamicin in higher-risk patients, which was found by multivariate analysis to be associated with a threefold reduction in infection risk (OR 3.0, 95% CI, 1.0-10.0).

Conclusion

These findings suggest that use of antibiotics, particularly gentamicin, in biologic envelope hydration solution may reduce infection risk, and use of antibacterial envelopes without adjunct IV ABX may not be sufficient to reduce CIED infections.

Clinical trial registration

[https://clinicaltrials.gov/], identifier [NCT02530970].

Risk Scores for Cardiac Implantable Electronic Device Infection: Which One to Believe In?

Infections are important complications of cardiac implantable electronic devices (CIED), with a high prognostic impact. Several risk factors for CIED infections are known. Different studies have been published proposing different risk scores, in order to preoperatively assess the individual likelihood of developing a CIED infection. Among the different scores, large heterogeneity exists and there is no consensus or convergence on a single score finding large applicability in global practice. The aim of this review is to comprehensively present and analyze all the available risk scores for CIED infection, with particular regard to the evidence of comparison studies.

Risk factors for cardiac implantable electronic device infections: a nationwide Danish study

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.

Prevention and Management of Cardiac Implantable Electronic Device Infections: State-of-the-Art and Future Directions

Cardiac implantable electronic device (CIED) infection is an increasingly common complication of device therapy. CIED infection confers significant patient morbidity and health care expenditure, hence it is essential that clinicians recognise the contemporary strategies for predicting, reducing and treating these events. Recent technological advances-in particular, the development of antimicrobial envelopes, leadless devices and validated risk scores-present decision-makers with novel strategies for managing this expanding patient population. This review summarises the key issues facing CIED patients and their physicians, and explores the supporting evidence for the latest therapeutic developments in this field.

Process Mapping Strategies to Prevent Subcutaneous Implantable Cardioverter-Defibrillator Infections

BACKGROUND

Infection remains a major complication of cardiac implantable electronic devices (CIEDs) and can lead to significant morbidity and mortality. Implantable devices that avoid transvenous leads, such as the subcutaneous implantable cardioverter-defibrillator (S-ICD), can reduce the risk of serious infection-related complications, such as bloodstream infection and infective endocarditis. While the 2017 AHA/ACC/HRS guidelines include recommendations for S-ICD use for patients at high risk of infection, currently, there are no clinical trial data that address best practices for the prevention of S-ICD infections. Therefore, an expert panel was convened to develop consensus on these topics.

METHODS

An expert process mapping methodology was used to achieve consensus on the appropriate steps to minimize or prevent S-ICD infections. Two face-to-face meetings of high-volume S-ICD implanters and an infectious diseases specialist, with expertise on cardiovascular implantable electronic device infections, were conducted to develop consensus on useful strategies pre-, peri-, and post-implant to reduce S-ICD infection risk.

RESULTS

Expert panel consensus of recommended steps for patient preparation, S-ICD implantation, and post-operative management were developed to provide guidance in individual patient management.

CONCLUSION

Achieving expert panel consensus by process mapping methodology for S-ICD infection prevention was attainable, and the results should be helpful to clinicians in adopting interventions to minimize risks of S-ICD infection. This article is protected by copyright. All rights reserved.

Temporal and Microbiological Analysis of Cardiac Implantable Electrical Device Infections - A Retrospective Study

Background: Although the causative pathogens in cardiac implantable electronic device (CIED) infections are well known, the relationship between time after implantation and infection patterns has not been sufficiently investigated. This study investigated the microbiology and onset of CIED infections according to infection patterns.

Methods and Results: This retrospective study included 97 patients who underwent CIED removal due to device-related infections between April 2009 and December 2018. After device implantation, infections peaked in the first year and declined gradually over 10 years. Most infections (>60%) occurred within 5 years. Staphylococcal infections, the predominant form of CIED infections, occurred throughout the study period. CIED infections were categorized as systemic (SI; n=26) or local (LI; n=71) infections according to clinical presentation, and as CIED pocket-related (PR; n=85) and non-pocket-related (non-PR; n=12) infections according to the pathogenic pathway. The main causative pathogen in SI was Staphylococcus aureus, whereas coagulase-negative staphylococci were mainly related to LI. Both SI and LI peaked in the first year after implantation and then decreased gradually. There was no significant microbiological difference between PR and non-PR infections. PR infections showed the same temporal distribution as the overall cohort. However, non-PR infections exhibited a uniform temporal distribution after the first year.

Conclusions: The severity of CIED infections depends on the causative pathogen, whereas their temporal distribution is affected by the microbiological intrusion pathway.

Epidemiology of cardiac implantable electronic device infections: incidence and risk factors

Cardiac implantable electronic device (CIED) infection is a potentially devastating complication of CIED procedures, causing significant morbidity and mortality for patients. Of all CIED complications, infection has the greatest impact on mortality, requirement for re-intervention and additional hospital treatment days. Based on large prospective studies, the infection rate at 12-months after a CIED procedure is approximately 1%. The risk of CIED infection may be related to several factors which should be considered with regards to risk minimization. These include technical factors, patient factors, and periprocedural factors. Technical factors include the number of leads and size of generator, the absolute number of interventions which have been performed for the patient, and the operative approach. Patient factors include various non-modifiable underlying comorbidities and potentially modifiable transient conditions. Procedural factors include both peri-operative and post-operative factors. The contemporary PADIT score, derived from a large cohort of CIED patients, is useful for the prediction of infection risk. In this review, we summarize the key information regarding epidemiology, incidence and risk factors for CIED infection.

Therapy and outcomes of cardiac implantable electronic devices infections

Cardiac implantable electronic device (CIED) infection causes significant morbidity and mortality without appropriate treatment. It can present as incisional infection, pocket infection, systemic CIED infection, or occult bacteraemia. Complete percutaneous CIED extraction (excepted in case of incisional infection) and appropriate antibiotic therapy are the two main pillars of therapy. Device reimplantation, if needed, should be delayed sufficiently to allow control of the infection. Here, we address the differences in prognosis according to the clinical scenario and the different treatment options.

Clinical manifestations of device-related infective endocarditis in cardiac resynchronization therapy recipients

INTRODUCTION

The aim of the study was to analyse microbiological characteristics and clinical manifestations of cardiac device-related infective endocarditis (CDRIE) in cardiac resynchronization therapy (CRT) recipients, and to compare the diagnostic value of modified Duke (MDC) versus modified Duke lead criteria (MDLC; including to MDC local infection and pulmonary infection or embolism as major criteria).

MATERIAL AND METHODS

The study population comprised 765 consecutive CRT patients from a high-volume, tertiary care centre from 2002 to 2015. All patients were screened for CDRIE.

RESULTS

During a median follow-up of 1692 days (range: 457-3067) 5.36% of patients (n = 41) developed CDRIE, which was accompanied by CRT pocket infection in 17.1% (n = 7) and recurrent pulmonary infection or pulmonary embolism in 29.3% (n = 12). Fever was present in 95.1% of patients (n = 39), whereas blood cultures were positive in 65.9% (n = 27). Staphylococcus was the most prevalent pathogen in 59.3% (n = 16), Gram-negative bacteria in 25.9% (n = 7). Transoesophageal echocardiography showed intracardiac vegetations in 73.2% of patients (n = 30). Non-different pathogen types with the most common methicillin-sensitive Staphylococcus aureus were observed for early versus late CDRIE (endocarditis ≤ 6 vs. > 6 months from CRT or other device-related procedure). All 3 inflammatory markers (C-reactive protein, white blood cells, procalcitonin) were normal in 4.9% of patients (n = 2). MDC versus MDLC indicated definite CDRIE in 48.8% versus 80.5%, respectively (p = 0.003).

CONCLUSIONS

Fever is the most common symptom of CRT-related CDRIE, and transoesophageal echocardiography allows vegetations to be visualised in nearly 3/4 of patients with CDRIE. Although the most common pathogens were Staphylococci, Gram-negative bacteria accounted for a quarter of CDRIE. Modified Duke lead criteria proved superior to MDC.

High prevalence of anti-HEV antibodies among patients with immunosuppression and hepatic disorders in eastern Poland

INTRODUCTION

The incidence of hepatitis E virus (HEV) infections in Poland is largely unknown. This study aimed to describe seroprevalence of markers of HEV infection among patients with immunodeficiency of diverse etiology and patients with advanced chronic liver diseases.

MATERIAL AND METHODS

Four hundred fifty patients were enrolled; among them, 180 persons were solid organ transplant recipients, 90 patients were HIV-infected and 180 persons had confirmed liver cirrhosis of different etiology. Serum anti-HEV-IgG, IgM antibodies and HEV-antigen were detected by ELISA (Wantai, China).

RESULTS

In the group of transplant recipients, serum anti-HEV-IgG antibodies were detected in 40.6%, IgM in 1.1% and HEV-Ag in 2.8% of subjects. In the HIV-infected population 37.7% had anti-HEV-IgG, 1.1% had anti-HEV-IgM and none had HEV-Ag. Among patients with advanced chronic liver diseases the highest prevalence of anti-HEV-IgG was recorded in alcohol-related liver cirrhosis (52.1%) (p = 0.049). In the population of all liver cirrhotics anti-HEV-IgG seroprevalence was 48.3%, anti-HEV-IgM seroprevalence was 5.0% and HEV-Ag seroprevalence was 1.7%. Older age and male gender were significant risk factors associated with increased anti-HEV-IgG prevalence, p = 0.0004 and p = 0.02, respectively.

CONCLUSIONS

In this large cohort a high seroprevalence of anti-HEV-IgG was detected in comparison to other European countries, with the highest rates in patients with alcoholic liver disease and in transplant recipients.

Economic impact of cardiac implantable electronic device infections: cost analysis at one year in a large U.S. health insurer

Aims: Cardiac device infections (CDIs) are serious adverse events associated with morbidity and mortality, significant costs and increased healthcare utilization. The objective of the current study was to characterize the CDI rate by device type, risk factors for infection and healthcare costs from a large U.S. health insurer perspective.Materials and Methods: A retrospective analysis of a large U.S. health insurer database identified commercial and Medicare Advantage with Part D (MAPD) members ≥18 years with ≥1 claim for a cardiac implantable electronic device (CIED) procedure between 01 October 2011 and 31 October 2015. CIEDs included pacemakers (IPG), implantable cardioverter defibrillators (ICDs), and cardiac resynchronization therapy - pacemakers without (CRT-P) and with defibrillation (CRT-D). Probabilities of CDI through one-year post implant were estimated using the Kaplan-Meier method. A regression model with stepwise variable selection was used to select risk factors associated with CDIs.Results: A total of 63,406 patients were included with an overall CDI rate of 1.28% (1.0% de novo and 1.74% replacement devices), varying by device type: IPG = 0.91%; ICD = 1.63%; CRT-p = 1.50%; CRT-D = 2.22%. The average adjusted annual medical costs were 2.4 times greater [95% confidence interval (CI) = 2.1-2.7] for those with an infection compared to those without, and the incremental cost difference was estimated to be $57,322 [95% CI $46,572-$70,484]. Observed risk factors of CDIs included prior device infection [Odds ratio (OR) = 11.356; 95% CI = 7.923-16.276], undergoing a CIED replacement procedure (OR = 1.644; 95% CI = 1.361-1.987), implantation of a high-power device (OR = 1.354; 95% CI = 1.115-1.643), and younger age (age < 65) (OR = 1.607; 95% CI = 1.307-1.976).Conclusions: The CDI rate at one year ranged from 0.91%-2.22% depending on device type. Management of CDIs among commercial and MAPD members is associated with high healthcare expenditures.

Clinical outcomes of patients undergoing a cardiac implantable electronic device implantation following a recent non-device-related infection

BACKGROUND

Clinical outcomes of patients undergoing a cardiac implantable electronic device (CIED) implantation following a recent non-device related infection are unknown.

AIM

To evaluate the clinical outcomes of patients with recent infection before CIED implantation.

METHODS

Consecutive patients (N = 1237) were classified as patients with recent infection (N = 72) and without recent infection (N = 1165). A recent infection was established by reviewing medical records, including symptoms and clinical manifestations, diagnosis of systemic inflammatory response syndrome, and quick Sequential Organ Failure Assessment (qSOFA) score. Multiple stepwise logistic regression analysis was used to identify independent predictors of in-hospital all-cause mortality.

FINDINGS

During nearly three years of follow-up, 17 patients had CIED infection (1.4%), and the incidence of CIED infection did not significantly differ between patients with and without recent infection according to symptoms and clinical manifestations (2.8% vs 1.3%, respectively; not significant). However, patients with recent infection had a significantly higher in-hospital mortality rate compared to those without recent infection (22.2% vs 0.9%, respectively; P < 0.05). In multivariate analysis, predictors of in-hospital mortality were recent infection before CIED implantation (odds ratio: 20.3; 95% confidence interval: 8.4-49.3; P < 0.001) and end-stage renal disease (4.3; 1.4-12.8; P = 0.009).

CONCLUSION

A CIED implantation is feasible in patients with recent infection if the patient is afebrile and has received an adequate duration of antibiotic therapy. Participants in shared decision-making before implant should be advised that recent infection increases in-hospital mortality risk, especially in patients with a qSOFA score of ≥2.

Analysis of Outcomes in 8304 Patients Undergoing Lead Extraction for Infection

Background Patients undergoing lead extraction for infected devices have worse outcomes compared with those with noninfected devices. We assessed predictors of in-hospital mortality and procedure-related major adverse events (MAEs) in a large cohort undergoing lead extraction. Methods and Results Deidentified hospital records procedure from 7 states between 1994 and 2013 were aggregated and International Classification of Disease, Ninth Revision (ICD-9) procedure codes were used to identify hospital records reporting lead extraction. MAEs included death, cardiac tamponade, hemothorax, and need for emergent cardiac surgery. Predictors of in-hospital MAEs for infected compared with noninfected leads were identified using multivariate regression. Associations between outcomes and specific microbe were also assessed. In total, 57 220 discharges specified lead extraction. Infected leads accounted for the minority of total lead extractions compared with fractured leads (16.1 versus 59.8%, 25.7% not reported). There were 3298 MAEs (5.8%) including 980 deaths (1.7%). Multivariate predictors of MAE included black race, atrial fibrillation, anemia, heart failure, and admission via either hospital transfer or emergency department versus home (all P<0.001). Infected leads were associated with an increased risk of death (4.6% versus 0.9%, P<0.001) compared with leads with fracture only. Among patients with microbial data, staphylococcal infection was most common, whereas streptococcal infection was associated with the worst outcomes. Conclusions Patients undergoing extraction of infected leads have higher in-hospital mortality and adverse events compared with noninfected leads. Streptococcus, anemia, and heart failure are predictors of adverse outcomes.

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.

Prevalence of Implanted Medical Devices in Medicine Inpatients

Implanted medical devices (IMDs) are extremely common, yet they are not systematically documented on hospital admission. Through structured patient interviews, we determined the prevalence of IMDs in hospital inpatients. Using medical record review, we evaluated the sensitivity of the medical record reporting of IMDs on an academic medical inpatient service. Fifty-eight percent of 191 interviewees reported 1 or more IMDs. Participants who reported greater than 1 IMD were older and had more frequent hospitalizations. The most common devices reported were surgical mesh, screws, plates, or wires (n = 47); intravascular stents (n = 25); and prosthetic joint replacements (n = 17). Forty-six patients (24%) reported greater than 1 IMD that had not been recorded in their admission history and physical examination. The prevalence of IMDs in hospitalized patients is high and underestimated in the medical record and may have significant implications for patient care.

Trends of Cardiovascular Implantable Electronic Device Infection in 3 Decades: A Population-Based Study

OBJECTIVES

This study assessed trends in the incidence of cardiovascular implantable electronic device (CIED) infection in the last 3 decades using a population-based records linkage study.

BACKGROUND

Infection remains an important issue associated with increased implantation rate and dwell time of CIEDs.

METHODS

We identified a cohort of all adults with CIEDs who resided in Olmsted County, Minnesota, from 1988 to 2015, using the medical linkage system of the Rochester Epidemiology Project. Standardized criteria were used to identify all CIED infection cases. The cumulative rate of CIED infection was estimated using the Kaplan-Meier method, and the trends of CIED infection incidence were calculated with person-years of follow-up after device implantation.

RESULTS

The cumulative probabilities of overall CIED infection were 6.2% (95% confidence interval [CI]: 4.0% to 8.4%) at 15 years and 11.7% (95% CI: 6.8% to 17.3%) at 25 years of follow-up. The incidence of CIED infection every 7 years from 1988 to 2015 was 1.3, 5.7, 4.1, and 4.7 per 1,000-person years, respectively. The 15-year cumulative probabilities of CIED infection after the initial, second, and third procedures were 2.6% (95% CI: 1.4% to 3.8%), 2.7% (95% CI: 1.2% to 4.2%), and 24.1% (95% CI: 3.8% to 44.4%), respectively. Generator changes (hazard ratio [HR]: 3.91; 95% CI: 1.47 to 10.37; p = 0.006) and upgrades (HR: 3.08; 95% CI: 1.24 to 7.62; p = 0.02) were significantly associated with infection.

CONCLUSIONS

The incidence of CIED infection had a trend of increasing in the past 2 decades. Contemporary implantable cardioverter-defibrillator and cardiac resynchronization therapies and repeated manipulation of device pockets introduced a greater risk of CIED infection.

The predictors and economic burden of early-, mid- and late-onset cardiac implantable electronic device infections: a retrospective cohort study in Ontario, Canada

The rate of cardiac implantable electronic device (CIED) infection is increasing with time. We sought to determine the predictors, relative mortality, and cost burden of early-, mid- and late-onset CIED infections. We conducted a retrospective cohort study of all CIED implantations in Ontario, Canada between April 2013 and March 2016. The procedures and infections were identified in validated, population-wide health-care databases. Infection onset was categorized as early (0-30 days), mid (31-182 days) and late (183-365 days). Cox proportional hazards regression was used to assess the mortality impact of CIED infections, with infection modelled as a time-varying covariate. A generalized linear model with a log-link and γ distribution was used to compare health-care system costs by infection status. Among 17 584 patients undergoing CIED implantation, 215 (1.2%) developed an infection, including 88 early, 85 mid, and 42 late infections. The adjusted hazard ratio (aHR) of death was higher for patients with early (aHR 2.9, 95% CI 1.7-4.9), mid (aHR 3.3, 95% CI 1.9-5.7) and late (aHR 19.9, 95% CI 9.9-40.2) infections. Total mean 1-year health costs were highest for late-onset (mean Can$113 778), followed by mid-onset (mean Can$85 302), and then early-onset (Can$75 415) infections; costs for uninfected patients were Can$25 631. After accounting for patient and procedure characteristics, there was a significant increase in costs associated with early- (rate ratio (RR) 3.1, 95% CI 2.3-4.1), mid- (RR 2.8, 95% CI 2.4-3.3) and late- (RR 4.7, 95% CI 3.6-6.2) onset infections. In summary, CIED infections carry a tremendous clinical and economic burden, and this burden is disproportionately high for late-onset infections.

Predictors of Bloodstream Infection in Patients Presenting With Cardiovascular Implantable Electronic Device Pocket Infection

Background

Generator pocket infection is the most frequent presentation of cardiovascular implantable electronic device (CIED) infection. We aim to identify predictors of underlying bloodstream infection (BSI) in patients presenting with CIED pocket infection.

Methods

We retrospectively reviewed all adults with CIED pocket infection cared for at our institution from January 2005 through January 2016. The CIED pocket infection cases were then subclassified as with or without associated BSI. Variables with P values <.05 at univariate analysis were included in a multivariable model to identify independent predictors of underlying BSI.

Results

We screened 429 cases of CIED infection, and 95 met the inclusion criteria. Of these, 68 cases (71.6%) were categorized as non-BSI and 27 (28.4%) as BSI. There were no statistically significant differences in patient comorbid conditions or device characteristics between the 2 groups. In multivariable analysis, the presence of systemic inflammatory response syndrome criteria (tachycardia, tachypnea, fever or hypothermia, and leukocytosis or leukopenia) and hypotension were independent predictors of underlying BSI in patients presenting with CIED pocket infection. Overall, patients in the non-BSI group who did not receive pre-extraction antibiotics had a higher frequency of positive intraoperative pocket/device cultures than those with pre-extraction antibiotic exposure (79.4% vs 58.6%; P = .06).

Conclusions

Patients with CIED pocket infection who meet systemic inflammatory response syndrome criteria and/or are hypotensive at admission are more likely to have underlying BSI and should be started on empiric antibiotics after blood cultures are obtained. If these features are absent, it may be reasonable to withhold empiric antibiotics to optimize yield of pocket/device cultures during extraction.

Cardiac implantable electronic device infection in the cardiac referral center in Thailand: incidence, microbiology, risk factors, and outcomes

BACKGROUND

Despite the long experience of cardiac implantable electronic device (CIED) implantation in Thailand, epidemiology of CIED infection in Thailand has never been studied.

METHODS

A retrospective cohort study was conducted at the cardiac referral center in Thailand to investigate incidence of CIED infection and causative organisms between October 2002 and December 2017. A matched case-control study was performed to determine the factors associated with CIED infection.

RESULTS

Incidence of CIED infection was 0.9% with a stable trend during the studied period. There were 54 episodes of CIED infection. The median (interquartile range) age of the patients was 67.5 (53.0-75.0) years. A total of 29 (53.7%), 18 (33.3%), and 7 (13.0%) were permanent pacemaker, automatic implantable cardioverter-defibrillator, and cardio-resynchronization therapy-related infection, respectively. Gram-positive cocci were the most common organism (24 episodes, 44.4%). Gram-negative bacilli were isolated in six episodes (11.1%). About 9.3% were polymicrobial and 35.2% were culture negative. Multivariate analysis showed that previous CIED infection and generator revision procedure were associated with CIED infection (odds ratio [OR] 48.56, 95% confidence interval [CI] 3.72-633.62; P = 0.003 and OR 19.99, 95% CI 1.28-333.24; P = 0.033 respectively). Forty (74.1%) cases were cured. Leaving device in situ was the only factor significantly associated with poor outcome (OR 11.40, 95% CI 1.52-85.73; P = 0.018).

CONCLUSIONS

In Thailand, while CIED implantation is rising, incidence of CIED infection is stable. Microbiology of CIED infection in Thailand is similar to western countries, albeit a higher proportion of negative culture. Previous CIED infection and generator revision procedure are associated with CIED infection.

Infective endocarditis and risk of death after cardiac implantable electronic device implantation: a nationwide cohort study

Aims

To determine the incidence, risk factors, and mortality of infective endocarditis (IE) following implantation of a first-time, permanent, cardiac implantable electronic device (CIED).

Methods and results

From Danish nationwide administrative registers (beginning in 1996), we identified all de-novo permanent pacemakers (PMs) and implantable cardioverter defibrillators (ICDs) together with the occurrence of post-implantation IE-events in the period from 2000-2012. Included were 43 048 first-time PM/ICD recipients. Total follow-up time was 168 343 person-years (PYs). The incidence rate (per 1000 PYs) of IE in PM was 2.1 (95% confidence interval [CI]: 1.7-2.6) for single chamber devices and 6.2 (95% CI: 4.5-8.7) for cardiac resynchronization therapy (CRT); similarly, the rate of IE in ICD was 3.7 (95% CI: 2.9-4.7) in single chamber devices and 6.3 (95% CI: 4.4-9.0) in CRT. In multivariable analysis, increased PM complexity served as independent risk factor for IE {dual chamber PM [hazard ratio (HR) 1.39; 95% CI: 1.07-1.80] and CRT [HR: 1.84; 95% CI: 1.20-2.84]}. During follow-up, generator replacement (HR: 2.79; 95% CI: 1.87-4.17) and lead revision (HR: 4.33; 95% CI: 3.25-5.78) in PMs were associated with increased risk. Corresponding estimates in ICDs were 2.49 (95% CI: 1.28-4.86) and 6.58 (95% CI: 4.49-9.63). Risk of death after IE was significantly increased in PM and ICD with HRs of 1.56 (95% CI: 1.33-1.82) and 2.63 (95% CI: 2.00-3.48), respectively.

Conclusion

The risk of IE increased with increasing PM complexity. Other important risk factors were subsequent generator replacement and lead revision. IE was associated with an increased risk of mortality in the area of CIED.

Leadless pacemaker implantation after explantation of infected conventional pacemaker systems: A viable solution?

BACKGROUND

Conventional cardiac device infections are increasing in incidence, causing significant morbidity and mortality. Leadless pacemaker (LP) therapy may provide new opportunities for the management of pacemaker (PM) infections as it does not require implantation of transvenous leads and a pectoral pocket.

OBJECTIVE

We sought to evaluate the effect of early and late LP implantation in patients diagnosed with device infection.

METHODS

Patients receiving an LP at our center after conventional PM lead extraction due to infection between December 1, 2013 and November 30, 2017 were included.

RESULTS

A total of 17 patients (mean age 77.4 ± 7.77 years) underwent LP implantation (ie, 11 with Nanostim leadless cardiac pacemaker [Abbott, Chicago, IL] and 6 with Micra transcatheter pacing system [Medtronic, Minneapolis, MN]) after successful PM system explantation. In 9 PM-dependent patients, a temporary transvenous pacing system was placed as a bridge to permanent LP implantation. Early LP implantation was performed in 6 patients (<1 week), and in the remaining patients, the LP was placed at a later stage (>1 week). All patients experienced no LP infection during a mean follow-up of 16 ± 12 months, including 7 patients with a history of recurrent device infections with a mean follow-up of 20 ± 14 months.

CONCLUSION

Early and late LP placement after infected conventional pacing system explantation was a viable option in our case series. This therapy may provide an alternative strategy in the management of device infection, if confirmed by subsequent prospective randomized trials, particularly for patients who are PM dependent or have a history of recurrent device infections.

New Insights into Predictors of Cardiac Implantable Electronic Device Infection

Infection is an important complication of cardiac implantable electronic device procedures. To further study the factors associated with infection, we retrospectively reviewed the records of 3,205 consecutive patients who had undergone de novo or revision cardiac electronic device implantation at our institution from March 2011 through March 2015. We recorded all infections and specified whether they were related to the characteristics of the patient, device, or procedure. To identify predictors of infection, we performed multivariate analysis. Device infections were identified in 85 patients (2.7%), at a mean follow-up time of 27 ± 11 months. The main predictors of device infection were use of an implantable cardioverter-defibrillator or a cardiac resynchronization therapy defibrillator device (odds ratio [OR]=16; 95% CI, 4.14-61.85; P=0.0001), stage 3 chronic kidney disease (OR=9.41; 95% CI, 1.77-50.04; P=0.009), a revision procedure (OR=8.8; 95% CI, 3.37-23.2; P=0.0001), or postoperative hematoma (OR=6.9; 95% CI, 1.58-30.2; P=0.01). We also identified 2 novel predictors of infection: a low body mass index of <20 kg/m² (OR=1.03; 95% CI, 1.01-1.06; P=0.005), and use of povidone-iodine rather than chlorhexidine-alcohol for topical antisepsis (OR=4.4; 95% CI, 2.01-9.4; P=0.03). We conclude that comorbidities, device characteristics, procedure types, and postoperative noninfective complications all increase the risk of device infection after a cardiac implantable electronic device procedure.

Clinical presentation of CIED infection following initial implant versus reoperation for generator change or lead addition

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.

Cardiac implantable electronic device hematomas: Risk factors and effect of prophylactic pressure bandaging

BACKGROUND

Cardiac implantable electronic device (CIED) hematomas are associated with many adverse outcomes. We examined the incidence and risk factors associated with hematoma formation post-CIED implantation, and explored the preventative effect of prophylactic pressure bandaging (PPB) in a large tertiary center.

METHODS

1,091 devices were implanted during October 2011-December 2014. Clinically significant hematomas (CSH) were those that necessitated prolonged admission, including those due to reoperation, and clinically suspicious hematomas were swellings noted by medical/nursing staff. We screened for variables affecting hematoma incidence prior to conducting multivariate logistic regression analyses, one for all hematomas and one for CSH.

RESULTS

61 hematomas were identified (5.6% of patients), with 12 of those clinically significant (1.1% of patients). Factors significantly increasing the odds of developing any hematoma were stage 2 (odds ratio [OR] = 2.93, 95% confidence interval [CI] [1.08-7.94], P = 0.034) and 3 chronic kidney disease (CKD) (OR = 3.39 [1.20-9.56], P = 0.021), unfractionated heparin/therapeutic enoxaparin (OR = 3.15 [1.22-8.14], P = 0.018), and dual antiplatelets-aspirin + clopidogrel (OR = 2.95 [1.14-7.65], P = 0.026) + other combinations. Body Mass index (BMI) 25.0-29.9 (OR 0.52 [0.28-0.98], P = 0.044) and >30 were associated with decreased hematoma risk (OR 0.43 [0.20-0.91], P = 0.028). Factors significant for CSH formation were unfractionated heparin/therapeutic enoxaparin (OR = 9.55 [1.83-49.84], P = 0.007) and aspirin + clopidogrel (OR = 7.19 [1.01-50.91], P = 0.048). PPB nonsignificantly increased the odds of total hematoma development (OR = 1.53 [0.87-2.69], P = 0.135), and reduced CSH (OR = 0.67 [0.18-2.47], P = 0.547).

CONCLUSIONS

Heparin and dual antiplatelet use remain strong predictors of overall hematoma formation. CKD is a comparatively moderate predictor. BMI > 25 may decrease the risk of hematoma formation. PPB had nonsignificant effects on hematoma development.

Strategies to prevent infections associated with cardiovascular implantable electronic devices

INTRODUCTION

Infections involving cardiovascular implantable electronic devices (CIED) are associated with high morbidity and mortality and substantial financial cost. In the past two decades, the rate of CIED infections has increased disproportionate to the number of devices implanted, likely due to aging patient population with multiple comorbidities. Microbial contamination of the generator pocket and or leads by skin flora at the time of implantation is a major mechanism for early CIED infections. Due to resistance to host immune cells and antibiotics caused by biofilm formation, complete removal of the device generator and leads is required to achieve cure. Areas covered: In this manuscript, we review the published literature regarding epidemiology, risk factors, and pathogenesis of CIED infections with primary focus on the preventative strategies to reduce the incidence of device infections. Expert commentary: Strict adherence to infection control measures at the time of CIED implantation is critical in reducing the risk of device infection while adjunctive strategies such as use of antimicrobial envelopes might help in certain high-risk individuals. Technological advances in device manufacturing with availability of subcutaneous devices without transvenous leads and self-contained intracardiac devices without leads and generator show promise with lower risk of infection.

In-hospital complications after implantation of cardiac implantable electronic devices: Analysis of a national inpatient database in Japan

BACKGROUND

Complications after implantation of cardiac implantable electronic devices (CIEDs), including permanent pacemakers (PMs) and other CIEDs, are associated with increased patient mortality and healthcare costs. This study aimed to investigate overall complications after implantation of CIEDs, analyze the associated risk factors, and compare complications after PM implantation between hospitals that performed only PM implantations (PM-only hospitals) and hospitals that implanted other CIEDs, as well as PMs (all-CIED hospitals).

METHODS

Using the Japanese Diagnosis Procedure Combination database, we retrospectively collected data on inpatients who underwent CIED implantation from 1 July 2010 to 31 March 2014.

RESULTS

A total of 77,324 patients were identified, including 64,951 patients with PMs and 12,373 with other CIEDs. The overall incidences of in-hospital complications were 2.5% in patients with PMs and 2.1% in those with other CIEDs. The incidences of pocket infections, pocket problems, device- and lead-related problems, and sepsis were 0.9%, 0.5%, 0.4%, and 0.3%, respectively. The crude proportion of complications after PM implantation was higher in the PM-only hospitals than in the all-CIED hospitals (3.1% vs. 2.1%), but the multivariable logistic regression analysis showed no significant difference (odds ratio, 1.29; 95% confidence interval, 0.99-1.68).

CONCLUSION

After adjusting for patient backgrounds, the occurrence of complications after PM implantation was not significantly different between patients in PM-only hospitals and those in all-CIED hospitals.

Cardiac implantable electronic device infections: Who is at greatest risk?

BACKGROUND

Cardiac implantable electronic device (CIED) infections are associated with hospitalization, mortality, increased costs, and adverse outcomes.

OBJECTIVE

Determine the burden of infections for CIEDs based on device type, associated comorbidities, and clinical characteristics over a 12-year period.

METHODS

Utilizing data from the National Inpatient Sample database for cases from 2000 through 2012, we identified procedures for device-related infection (DRI) using International Statistical Classification of Diseases and Related Health Problems, Ninth Revision, Clinical Modification (ICD-9-CM) codes for CIED removal with diagnosis codes for device-related infection or systemic infection. Cases were categorized into 4 groups: single-chamber pacemaker, dual-chamber pacemaker, cardiac resynchronization therapy (CRT) device, and intracardiac defibrillator (ICD).

RESULTS

Of 4,144,683 device-related procedures, 85,203 (2.06%) were associated with DRI. From 2000 through 2012, procedures related to DRI increased from 1.45% to 3.41% (P < .001). The risk of infection for CRT devices was the highest, peaking in 2012 (adjusted odds ratio [OR] 2.43, P < .001). During second half of the study, comorbidities associated with DRI were diabetes (OR: 1.11, P < .001), end-stage renal disease (OR: 3.23, P < .001), hematoma (OR: 2.44, P < .001), malnutrition (OR: 2.66, P < .001), venous thromboembolism (OR: 2.37, P < .001), chronic kidney disease (OR: 1.26, P < .001), and organ transplantation (OR: 2.37, P < .001). Charges associated with CRT DRIs increased nearly 2-fold in a decade. Higher inpatient mortality related to device infection were stroke (OR: 3.19, P < .001), end-stage renal disease (OR: 2.91, P < .001), malnutrition (OR: 2.67, P < .001), cirrhosis (OR: 2.05, P = .001), and organ transplantation (OR: 2.16, P < .001).

CONCLUSION

CIED infections are increasing for all device types and particularly for CRT devices. Precise reasons for rising DRI procedures remain unclear, although conditions leading to immune compromise appear significant.

Device-related infective endocarditis in cardiac resynchronization therapy recipients - Single center registry with over 2500 person-years follow up

AIM

To assess incidence, predisposing factors and outcomes of cardiac device-related infective endocarditis (CDRIE) in patients undergoing cardiac resynchronization therapy (CRT).

METHODS AND RESULTS

High-volume, single-center cardiology database was screened to identify all CDRIE cases, based on modified Duke criteria, amongst 765 consecutive CRT implantations between 2002 and 2015 (70.8% de novo implantations, 13.7% and 15.5% up-grades from pacemaker and implantable cardioverter–defibrillator [ICD], respectively). During the median follow-up (FU) of 1207 days (range: 256–2664) overall 38 CDRIE (4.97%) cases were identified (incidence: 15/1000 person-years). Multivariate Cox regression model, incorporating significant baseline differences as covariates (model 1), demonstrated that both up-grade from ICD to CRT and higher baseline NYHA class were independently associated with increased risk of CDRIE (adjusted HR 4.29, 95%CI 1.93–9.57; and HR 2.43, 95%CI 1.32–4.49, respectively). In the second model (including all differences with P < 0.2) up-grade from ICD (HR 4.36, 95%CI 1.96–9.69), higher NYHA class (HR 2.04, 95%CI 1.11–3.75), hypertrophic cardiomyopathy (HR 5.85, 95% CI 1.46–23.52), lower baseline hemoglobin level (HR 0.68, 95%CI 0.50–0.94) and chronic obstructive pulmonary disease (HR 2.46, 95%CI 1.05–5.77) were all independently associated with higher risk of CDRIE. All-cause mortality in patients with CDRIE was significantly higher than in subjects without infective complications (68.4% vs. 33.7%, P < 0.001), and 50% of patients with CDRIE died during index hospitalization.

CONCLUSIONS

The prevalence of CDRIE in CRT recipients is almost 5% within 3.5 years post implantation. Up-grade from ICD and high baseline NYHA class flag up patients at high-risk of CDRIE. CRT-related infective complications are associated with very poor prognosis.

Subcutaneous defibrillator implantation in pediatric patients

OBJECTIVE

Although sudden cardiac death is rare in children, an intracardiac defibrillator system is indicated in children with various types of cardiomyopathy, primary electrical diseases, and after surgical repair of congenital heart defects. The use of transvenous defibrillator lead systems is limited in pediatric patients because of a small body size and/or limited vascular access. Subcutaneous array leads combined with an abdominally placed generator can enable implantation.

METHOD

This is a retrospective study of 13 patients who underwent subcutaneous defibrillator implantation between September 2010 and March 2015. The subcutaneous system was preferred because patients were not amenable to transvenous lead placement.

RESULTS

The median patient age was 4.1 years, and the median patient weight was 12.1 kg. Diagnoses of patients were long-QT syndrome in 6, aborted cardiac arrest with left ventricular non-compaction in 3, hypertrophic cardiomyopathy with sustained ventricular tachycardia in 3, and arrythmogenic right ventricular cardiomyopathy in 1. Revision of the subcutaneous lead was required in 5 patients 2-26 months after the implantation. Appropriate shocks were observed in three patients. Inappropriate shock and lead fractures were observed in one patient during the follow-up period. The failure of therapy was observed in one patient. There were no perioperative complications and no early or late deaths.

CONCLUSION

Subcutaneous defibrillator systems are safe and effective in pediatric patients when the transvenous method is risky and contraindicated. Because the high growth rate in this population leads to lead failures, a close follow-up of this population is essential.

Characteristics of cardiac device infections in the Isala Hospital; a large volume tertiary care cardiology centre

AIMS

To determine the frequency, characteristics and risk factors of cardiac device infections in the Isala Hospital.

METHODS

We retrospectively studied all patients who underwent cardiac device procedures performed in the cardiac catheterisation lab and the operating room from 2010 to 2012. All patients who developed a cardiac device infection were reviewed for its characteristics.

RESULTS

31/2026 patients developed a cardiac device infection (1.5 %). One (3.2 %) patient died within 30 days of hospitalisation. Device infection rates for procedures in the catheterisation lab and operating room were similar (p = 0.60). Positive cultures were present in 27/31 (87 %) cases. These consisted predominantly of micro-organisms that are part of the skin flora (84 %). The mean time between device procedure and infection was 14 ± 21 months (range 0-79). Cardiac device infection was significantly associated with device revision, (65 % were revisions in patients with device infection vs. 30 % revisions in patients without device infection, p = 0.011) and placement of a left ventricular lead in pacemaker implantations (59 % of patients with vs. 51 % of patients without device infection, p < 0.001).

CONCLUSION

The frequency of cardiac device infection was 1.5 % with a mortality of 3.2 % within 30 days, which is lower compared with other registries. Cardiac device infections were associated with device revisions and placement of left ventricular leads in pacemaker implantations.

Management of Cardiac Electronic Device Infections: Challenges and Outcomes

Cardiac implantable electronic device (CIED) infection is an increasing problem. Reasons for this are uncertain, but likely relate to an increasing proportion of implantable cardioverter defibrillator (ICD) and cardiac resynchronisation therapy (CRT) devices implanted, as well as implantations in 'higher risk' candidates, i.e. patients with heart failure, diabetes and renal failure. Challenges within the field of CIED infections are multiple with prevention being the most important challenge. Careful prescription of CIED treatment and careful patient preparation before implantation is important. Diagnosis is often difficult and delayed by subtle signs of infection. Treatment of CIED infection includes complete system removal in centres experienced in CIED extraction and prolonged antibiotic therapy. Meticulous planning and preparation before system extraction and later CIED re-implantation is essential for better patient outcome. Future strategies for reducing CIED infection should be tested in sufficiently powered, multicentre, randomised controlled trials.

Fistula Formation 6 Years after Removal of Infected Pacemaker Leads

We describe a case of a male patient who presented with a chronic ulcer below the left clavicle. Six years before the present admission a permanent pacemaker, including leads, was explanted related to endocarditis. The initial working hypothesis suspected an infected sebaceous gland as the cause of ulceration. After two periods of unsuccessful surgical treatment of the gland, further examination identified a small pacemaker lead fragment underneath the articulation between sternum and clavicle as a possible reason.

Efficacy of a Bio-Absorbable Antibacterial Envelope to Prevent Cardiac Implantable Electronic Device Infections in High-Risk Subjects

INTRODUCTION

Cardiac implantable electronic device (CIED) infections are potentially preventable complications associated with high morbidity, mortality, and cost. A recently developed bio-absorbable antibacterial envelope (TYRX™-A) might prevent CIED infections in high-risk subjects. However, data regarding safety and efficacy have not been published.

METHODS AND RESULTS

In a single-center retrospective cohort study, we compared the prevalence of CIED infections among subjects with ≥2 risk factors treated with the TYRX™-A envelope (N = 135), the nonabsorbable TYRX™ envelope (N = 353), and controls who did not receive an envelope (N = 636). Infection was ascertained by individual chart review. The mean (95% confidence interval) number of risk factors was 3.08 (2.84-3.32) for TYRX™-A, 3.20 (3.07-3.34) for TYRX™, and 3.09 (2.99-3.20) for controls, P = 0.3. After a minimum 300 days follow-up, the prevalence of CIED infection was 0 (0%) for TYRX™-A, 1 (0.3%) for TYRX™, and 20 (3.1%) for controls (P = 1 for TYRX™-A vs. TYRX™, P = 0.03 for TYRX™-A vs. controls, and P = 0.002 for TYRX™ vs. controls). In a propensity score-matched cohort of 316 recipients of either envelope and 316 controls, the prevalence of infection was 0 (0%) and 9 (2.8%), respectively, P = 0.004. When limited to 122 TYRX™-A recipients and 122 propensity-matched controls, the prevalence of CIED infections was 0 (0%) and 5 (4.1%), respectively, P = 0.024.

CONCLUSIONS

Among high-risk subjects, the TYRX™-A bio-absorbable envelope was associated with a very low prevalence of CIED related infections that was comparable to that seen with the nonabsorbable envelope.

Impact of Pacemaker Lead Characteristics on Pacemaker Related Infection and Heart Perforation: A Nationwide Population-Based Cohort Study

Background

Several risk factors for pacemaker (PM) related complications have been reported. However, no study has investigated the impact of lead characteristics on pacemaker-related complications.

Methods and Results

Patients who received a new pacemaker implant from January 1997 to December 2011 were selected from the Taiwan National Health Insurance Database. This population was grouped according to the pacemaker lead characteristics in terms of fixation and insulation. The impact of the characteristics of leads on early heart perforation was analyzed by multivariable logistic regression analysis, while the impact of the lead characteristics on early and late infection and late heart perforation over a three-year period were analyzed using Cox regression. This study included 36,104 patients with a mean age of 73.4±12.5 years. In terms of both early and late heart perforations, there were no significant differences between groups across the different types of fixation and insulations. In the multivariable Cox regression analysis, the pacemaker-related infection rate was significantly lower in the active fixation only group compared to either the both fixation (OR, 0.23; 95% CI, 0.07–0.80; P = 0.020) or the passive fixation group (OR, 0.26; 95% CI, 0.08–0.83; P = 0.023).

Conclusions

There was no difference in heart perforation between active and passive fixation leads. Active fixation leads were associated with reduced risk of pacemaker-related infection.

Prevention of infections in cardiovascular implantable electronic devices beyond the antibiotic agent

The increase in incidence/prevalence of infections of implantable pacemakers and defibrillators (implantable cardioverter defibrillator, ICD) is outweighing that of the implanting procedures, mainly favored by the changes in patient profile. Despite the high impact on patient's outcome and related costs for healthcare systems, we lack specific evidence on the preventive measures with the exception of antibiotic prophylaxis. The aim of this study is to focus on common approaches to pacemaker/ICD implantation to identify the practical preventive strategies and choices that can (potentially) impact on the occurrence of this feared complication. After a brief introduction on clinical presentation, pathogenesis, and risk factors, we will present the results from a survey on the preventive strategies adopted by different operators from the 25 centers of the Emilia Romagna region in the northern Italy (4.4 million inhabitants). These data will provide the basis for reviewing available literature on this topic and identifying the gray areas. The last part of the article will cover the available evidence about pacemaker/ICD implantation, focusing on prophylaxis of pacemaker/ICD infection as a 'continuum' starting before the surgical procedure (from indications to patient preparation), which follows during (operator, room, and techniques) and after the procedure (patient and device follow-up). We will conclude by evaluating the relationship between adherence to the available evidence and the volume of procedures of the implanting centers or operators' experience according to the results of our survey.

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)

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.

Increased long-term mortality in patients with cardiovascular implantable electronic device infections

BACKGROUND

Device infection is associated with increased mortality in patients receiving cardiovascular implantable electronic device (CIED) therapy. However, long-term mortality associated with CIED infections has not been systematically analyzed in larger studies. This study sought to determine the long-term mortality associated with CIED infection in a large cohort of Medicare beneficiaries.

METHODS

We used a retrospective study design to analyze 3-year mortality in 200,219 Medicare fee-for-service patients admitted for CIED generator implantation, replacement, or revision between January 1, 2007 and December 31, 2007. Multivariate analysis adjusting for age, sex, race, and 28 comorbidities was performed to determine the relative risk (RR) of death in the 12 quarters following CIED infection.

RESULTS

Patients with CIED infection, compared to device recipients without infection, had increased mortality that persisted for at least 3 years after the admission quarter for all device types: pacemakers (PMs: 53.8% vs 33%; P < 0.001), implantable cardioverter defibrillator (ICD: 47.7% vs 31.6%; P < 0.001), and cardiac resynchronization therapy-defibrillator (CRT-D: 50.8% vs 36.5%; P < 0.001). After adjusting for patient demographics and comorbidities, significantly increased RR of death following CIED infection persisted for at least 3 years following PM infection, and for at least 2 years with single- and dual-chamber ICD infection.

CONCLUSIONS

CIED recipients who develop device infection have increased, device-dependent, long-term mortality even after successful treatment of infection. The etiology of this persistent increased risk of death associated with CIED infection is unknown and merits further investigation.

Rate of cardiovascular implantable electronic device (CIED) re-extraction after recurrent infection

BACKGROUND

Patients who develop a cardiovascular implantable electronic device (CIED) infection requiring extraction may have risk factors that make them prone to developing another infection of the reimplanted CIED. However, the rate of a second infection requiring repeat extraction in such patients is unknown and may have important clinical implications.

METHODS

We retrospectively reviewed all patients at our institution from January 2001 to October 2012 who underwent a CIED extraction for an infection and then required reimplantation. We then reviewed the incidence of a repeat extraction due to a second infection. Clinical and device parameters at the time of the second infection were retrieved.

RESULTS

There were 168 patients who underwent a CIED extraction because of infection and were subsequently reimplanted. The median time to reimplantation was 3 [1(st) quartile: 1, 3(rd) quartile: 10] days. After a mean follow-up of 4.4 ± 2.7 years, nine (5.4%) patients underwent a repeat CIED extraction due to a second infection. Six repeat extractions (67%) occurred in the first year, leading to an event rate of 3.9% within 1 year of reimplantation. Patients with a second infection requiring a repeat CIED extraction were younger (57 ± 20 vs 68 ± 16, P = 0.046). Pocket infection was the most common presentation of a second infection, occurring in eight of the nine patients.

CONCLUSION

The rate of a second infection leading to a CIED repeat extraction is elevated within the first year after reimplantation. To determine predictors of recurring infection, analysis of a larger multicenter series is warranted.

Variability in clinical features of early versus late cardiovascular implantable electronic device pocket infections

BACKGROUND

Cardiovascular implantable electronic device (CIED) pocket infections are often related to recent CIED placement or manipulation, but these infections are not well characterized. The clinical presentation of CIED pocket infection, based on temporal onset related to last CIED procedure, deserves further study.

METHODS

The MEDIC (Multicenter Electrophysiologic Device Infection Cohort) prospectively enrolled subjects with CIED infection. Subjects were stratified into those whose infection occurred <12 months (early) or ≥ 12 months (late) since their last CIED-related procedure.

RESULTS

There were 132 subjects in the early group and 106 in the late group. There were more females (P = 0.009) and anticoagulation use (P = 0.039) in the early group. Subjects with early infections were more likely to have had a generator change or lead addition as their last procedure (P = 0.03) and had more prior CIED procedures (P = 0.023). Early infections were more likely to present with pocket erythema (P < 0.001), swelling (P < 0.001), and pain (P = 0.007). Late infections were more likely to have pocket erosion (P = 0.005) and valvular vegetations (P = 0.009). In bacteremic subjects, early infections were more likely healthcare-associated (P < 0.001). In-hospital and 6-month mortality were equivalent.

CONCLUSION

A total of 45% of patients with CIED pocket infection presented >12 months following their last CIED-related procedure. Patients with early infection were more likely to be female, on anticoagulation, and present with localized inflammation, whereas those with late infection were more likely to have CIED erosion or valvular endocarditis.