Evaluation of lead-based echodensities on transesophageal echocardiogram in patients with cardiac implantable electronic devices

State-of-the-Art Review: Complexities in Cardiac Implantable Electronic Device Infections: A Contemporary Practical Approach

Cardiac implantable electronic device infections (CIEDIs) present substantial challenges for infectious diseases specialists, encompassing diagnosis, management, and complex decision making involving patients, families, and multidisciplinary teams. This review, guided by a common clinical case presentation encountered in daily practice, navigates through the diagnostic process, management strategies in unique scenarios, long-term follow-up, and critical discussions required for CIEDIs.

How to Approach Patients with Cardiac Implantable Electronic Devices and Bacteremia

The approach to a patient with a cardiac implantable electronic device (CIED) and bacteremia requires a high index of suspicion. The microorganism and duration of bacteremia affect the pretest probability of CIED infection. When transesophageal echocardiography findings are equivocal, fluorodeoxyglucose-PET/computed tomography can increase the sensitivity and specificity for CIED infection. Confirmed CIED infection warrants complete system extraction. In patients with persistent gram-positive bacteremia despite antimicrobial therapy and unclear involvement of the CIED, the device is sometimes empirically extracted. Long-term effects of extraction (such as risk of suboptimal/failed cardiac resynchronization therapy reimplant) should be factored into decisions regarding empiric CIED extraction.

Cardiovascular Implantable Electronic Device Infections: A Contemporary Review

Infections associated with cardiac implantable electronic devices (CIEDs) are increasing and are a cause of significant morbidity and mortality. This article summarizes the latest updates with respect to the epidemiology, microbiology, and risk factors for CIED-related infections. It also covers important considerations regarding the diagnosis, management, and prevention of these infections. Newer technologies such as leadless pacemakers and subcutaneous implantable cardioverters and defibrillators are discussed.

Infective Endocarditis Involving Implanted Cardiac Electronic Devices: JACC Focus Seminar 1/4

Cardiac implantable electronic device-related infective endocarditis (CIED-IE) encompasses a range of clinical syndromes, including valvular, device lead, and bloodstream infections. However, accurately diagnosing CIED-IE remains challenging owing in part to diverse clinical presentations, lack of standardized definition, and variations in guideline recommendations. Furthermore, current diagnostic modalities, such as transesophageal echocardiography and [18F]-fluorodeoxyglucose positron emission tomography-computed tomography have limited sensitivity and specificity, further contributing to diagnostic uncertainty. This can potentially result in complications and unnecessary costs associated with inappropriate device extraction. Six hypothetical clinical cases that exemplify the diverse manifestations of CIED-IE are addressed herein. Through these cases, we highlight the importance of optimizing diagnostic accuracy and stewardship, understanding different pathogen-specific risks for bloodstream infections, guiding appropriate device extraction, and preventing CIED-IE, all while addressing key knowledge gaps. This review both informs clinicians and underscores crucial areas for future investigation, thereby shedding light on this complex and challenging syndrome.

Reappraisal of [18F]FDG-PET/CT for diagnosis and management of cardiac implantable electronic device infections

INTRODUCTION AND OBJECTIVES

The role of [18F]FDG-PET/CT in cardiac implantable electronic device (CIED) infections requires better evaluation, especially in the diagnosis of systemic infections. We aimed to determine the following: a) the diagnostic accuracy of [18F]FDG-PET/CT in each CIED topographical region, b) the added value of [18F]FDG-PET/CT over transesophageal echocardiography (TEE) in diagnosing systemic infections, c) spleen and bone marrow uptake in differentiating isolated local infections from systemic infections, and d) the potential application of [18F]FDG-PET/CT in follow-up.

METHODS

Retrospective single-center study including 54 cases and 54 controls from 2014 to 2021. The Primary endpoint was the diagnostic yield of [18F]FDG-PET/CT in each topographical CIED region. Secondary analyses described the performance of [18F]FDG-PET/CT compared with that of TEE in systemic infections, bone marrow and spleen uptake in systemic and isolated local infections, and the potential application of [18F]FDG-PET/CT in guiding cessation of chronic antibiotic suppression when completed device removal is not performed.

RESULTS

We analyzed 13 (24%) isolated local infections and 41 (76%) systemic infections. Overall, the specificity of [18F]FDG-PET/CT was 100% and sensitivity 85% (79% pocket, 57% subcutaneous lead, 22% endovascular lead, 10% intracardiac lead). When combined with TEE, [18F]FDG-PET/CT increased definite diagnosis o fsystemic infections from 34% to 56% (P=.04). Systemic infections with bacteremia showed higher spleen (P=.05) and bone marrow metabolism (P=.04) than local infections. Thirteen patients without complete device removal underwent a follow-up [18F]FDG-PET/CT, with no relapses after discontinuation of chronic antibiotic suppression in 6 cases with negative follow-up [18F]FDG-PET/CT.

CONCLUSIONS

The sensitivity of [18F]FDG-PET/CT for evaluating CIED infections was high in local infections but much lower in systemic infections. However, accuracy increased when [18F]FDG-PET/CT was combined with TEE in endovascular lead bacteremic infection. Spleen and bone marrow hypermetabolism could differentiate bacteremic systemic infection from local infection. Although further prospective studies are needed, follow-up [18F]FDG-PET/CT could play a potential role in the management of chronic antibiotic suppression therapy when complete device removal is unachievable.

Clinical Approach to Evaluation of Underlying Cardiac Device Infection in Patients Hospitalized with Bacteremia

More than 400,000 cardiac implantable electronic devices (CIEDs), including permanent pacemakers, implantable cardioverter-defibrillators, and cardiac resynchronization therapy devices, are implanted every year in the United States (US). Infection is a serious complication of CIED therapy and is associated with high morbidity and mortality. While CIED pocket infection can be diagnosed based on clinical exam findings, positive blood culture may be the only manifestation of CIED lead infection. Thus, management of bacteremia in patients living with CIEDs requires special consideration. This review summarizes contemporary data in the context of the recently updated 2023 Duke-International Society for Cardiovascular Infectious Diseases Criteria for Infective Endocarditis. We have synthesized these data into an algorithmic approach to streamline the diagnostic evaluation of CIED infection in patients presenting with bacteremia.

Risk of Cardiac Implantable Electronic Device Infection in Patients with Bloodstream Infection: Microbiologic Effect in the Era of Positron Emission Tomography-Computed Tomography

PURPOSE OF REVIEW

Bloodstream infection (BSI) in patients with cardiac implantable electronic devices (CIEDs) is common and can prompt challenges in defining optimal management. We provide a contemporary narrative review of this topic and propose a pathogen-dependent clinical approach to patient management.

RECENT FINDINGS

BSI due to staphylococci, viridans group streptococci, and enterococci is associated with an increased risk of underlying CIED infection, while the risk of CIED infection due to other organisms is poorly defined. There is growing evidence that positron emission tomography-computed tomography may be helpful in some patients with BSI and underlying CIED. Twenty studies were included to examine the impact of microbiologic findings on the risk of CIED infection among patients with BSI. Diagnosis of CIED infection in patients with BSI without pocket findings is often difficult, necessitating the use of novel diagnostic tools to help guide the clinician in subsequent patient management.