Prevalence and prognosis of lead masses in patients with cardiac implantable electronic devices without infection

Cardiac implantable electronic device infection

Cardiac implantable electronic device infections (CIEDI) are an important complication of device implantation associated with significant morbidity, mortality, and cost to the healthcare system. Identifying patients at high risk of device infection is paramount to improving decision making. This includes selecting appropriate devices and implementing adjunctive infection prevention measures, such as antimicrobial envelopes. In addition to meticulous antiseptic surgical technique, several other procedure-related practices can help reduce the risk of device infection. Developing expert centers with multidisciplinary teams capable of device extraction is important to manage patients with CIEDI. In this review, we aim to provide the reader with a succinct overview of CIEDI and summarize new evidence for risk assessment, prevention, diagnosis, and infection management.

What Important Information Does Transesophageal Echocardiography Provide When Performed before Transvenous Lead Extraction?

Background: Transesophageal echocardiography (TEE) is mandatory before transvenous lead extraction (TLE), but its usefulness remains underestimated. This study aims to describe the broad range of TEE findings in TLE candidates, as well as their influence on procedure complexity, major complications (MCs) and long-term survival. Methods: Preoperative TEE was performed in 1191 patients undergoing TLE. Results: Lead thickening (OR = 1.536; p = 0.007), lead adhesion to heart structures (OR = 2.531; p < 0.001) and abnormally long lead loops (OR = 1.632; p = 0.006) increased the complexity of TLE. Vegetation-like masses on the lead (OR = 4.080; p = 0.44), lead thickening (OR = 2.389; p = 0.049) and lead adhesion to heart structures (OR = 6.341; p < 0.001) increased the rate of MCs. The presence of vegetations (HR = 7.254; p < 0.001) was the strongest predictor of death during a 1-year follow-up period. Conclusions: TEE before TLE provides a lot of important information for the operator. Apart from the visualization of possible vegetations, it can also detect various forms of lead-related scar tissue. Build-up of scar tissue and the presence of long lead loops are associated with increased complexity of the procedure and risk of MCs. Preoperative TEE performed outside the operating room may have an impact on the clinical decision-making process, such as transferring potentially more difficult patients to a more experienced center or having the procedure performed by the most experienced operator. Moreover, the presence of masses or vegetations on the leads significantly increases 1-year and all-cause mortality.

Bacteraemia with gram-positive bacteria-when and how do I need to look for endocarditis?

BACKGROUND

Patients with bacteraemia caused by gram-positive bacteria are at risk for infective endocarditis (IE). Because IE needs long antibiotic treatment and sometimes heart valve surgery, it is very important to identify patients with IE.

OBJECTIVES

In this narrative review we present and discuss how to determine which investigations to detect IE that are needed in individual patients with gram-positive bacteraemia.

SOURCES

Published original studies and previous reviews in English, within the relevant field are used.

CONTENT

First, the different qualities of the bacteraemia in relation to IE risk are discussed. The risk for IE in bacteraemia is related to the species of the bacterium but also to monomicrobial bacteraemia and the number of positive cultures. Second, patient-related factors for IE risk in bacteraemia are presented. Next, the risk stratification systems to determine the risk for IE in gram-positive bacteraemia caused by Staphylococcus aureus, viridans streptococci, and Enterococcus faecalis are presented and their use is discussed. In the last part of the review, an account for the different modalities of IE-investigations is given. The main focus is on echocardiography, which is the cornerstone of IE-investigations. Furthermore, 18F-fluorodesoxyglucose positron emission tomography/computed tomography and cardiac computed tomography are presented and their use is also discussed. A brief account for investigations used to identify embolic phenomena in IE is also given. Finally, we present a flowchart suggesting which investigations to perform in relation to IE in patients with gram-positive bacteraemia.

IMPLICATIONS

For the individual patient as well as the healthcare system, it is important both to diagnose IE and to decide when to stop looking for IE. This review might be helpful in finding that balance.

Imaging in patients with cardiovascular implantable electronic devices: part 2-imaging after device implantation. A clinical consensus statement of the European Association of Cardiovascular Imaging (EACVI) and the European Heart Rhythm Association (EHRA) of the ESC

Cardiac implantable electronic devices (CIEDs) improve quality of life and prolong survival, but there are additional considerations for cardiovascular imaging after implantation-both for standard indications and for diagnosing and guiding management of device-related complications. This clinical consensus statement (part 2) from the European Association of Cardiovascular Imaging, in collaboration with the European Heart Rhythm Association, provides comprehensive, up-to-date, and evidence-based guidance to cardiologists, cardiac imagers, and pacing specialists regarding the use of imaging in patients after implantation of conventional pacemakers, cardioverter defibrillators, and cardiac resynchronization therapy (CRT) devices. The document summarizes the existing evidence regarding the role and optimal use of various cardiac imaging modalities in patients with suspected CIED-related complications and also discusses CRT optimization, the safety of magnetic resonance imaging in CIED carriers, and describes the role of chest radiography in assessing CIED type, position, and complications. The role of imaging before and during CIED implantation is discussed in a companion document (part 1).

Radionuclide Imaging of Infective Endocarditis

Infective endocarditis (IE) is associated with high morbidity and mortality. Early diagnosis is crucial for adequate patient management. Due to difficulties in the diagnosis, a multidisciplinary discussion in addition to the integration of clinical signs, microbiology data, and imaging data is used. Imaging, including echocardiography, molecular imaging techniques, and coronary CT angiography (CTA) is central to detect infections involving heart valves and implanted cardiovascular devices, also allowing for early detection of septic emboli and metastatic. This article describes the main clinical application of white blood cell SPECT/CT and [¹⁸F]FDG-PET/CT and CTA in IE and infections associated with cardiovascular implantable electronic devices.

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

INTRODUCTION

Transesophageal echocardiography (TEE) is recommended to rule out endocarditis in patients with cardiac implantable electronic devices (CIED). A lead-based echodensity (LBE), however, is often found on TEE in patients with a CIED and may not represent an infection. We sought to evaluate the predictors, characteristics, and clinical significance of LBEs seen on TEE in patients with a CIED.

METHODS

Patients with a CIED were retrospectively identified from a database using International Classification of Diseases (ICD)-9/ICD-10 codes and were cross-matched with Current Procedural Terminology codes for a TEE. Clinical and follow-up data were collected. A blinded echo board-certified cardiologist reviewed all TEEs.

RESULTS

Out of the 231 patients in the cohort, 191 had TEE performed for a noninfection-related indication while 40 TEEs were part of an endocarditis workup. A total of 50 LBEs were identified, and a majority were in the noninfection cohort. Systemic anticoagulant use in the noninfection cohort was associated with a decreased odds of having LBE on TEE (odds ratio [OR] of 0.23 [95% confidence interval [CI]: 0.06-0.60, p = .003]). Lead dwell time in the noninfection cohort was associated with an increased odds of having LBE on TEE (OR 1.21 (95% CI: 1.04-1.39, p = .009]).

CONCLUSION

In our cohort of patients who had TEE for noninfection indications we found that systemic anticoagulant use is associated with fewer LBEs on TEEs, suggesting possible thrombin fibrin composition of LBE.

"Ghost", a Well-Known but Not Fully Explained Echocardiographic Finding during Transvenous Lead Extraction: Clinical Significance

"Ghosts" are fibrinous remnants that become visible during transvenous lead extraction (TLE).

METHODS

Data from transoesophageal echocardiography-guided TLE procedures performed in 1103 patients were analysed to identify predisposing risk factors for the development of so-called disappearing ghosts-flying ghosts (FG), or attached to the cardiovascular wall-stable ghosts (SG), and to find out whether the presence of ghosts affected patient prognosis after TLE.

RESULTS

Ghosts were detected in 44.67% of patients (FG 15.5%, SG 29.2%). The occurrence of ghosts was associated with patient age at first system implantation [FG (OR = 0.984; p = 0.019), SG (OR = 0.989; p = 0.030)], scar tissue around the lead (s) [FG (OR = 7.106; p < 0.001, OR = 1.372; p = 0.011), SG (OR = 1.940; p < 0.001)], adherence of the lead to the cardiovascular wall [FG (OR = 0.517; p = 0.034)] and the number of leads [SG (OR = 1.450; p < 0.002). The presence of ghosts had no impact on long-term survival after TLE in the whole study group [FG HR = 0.927, 95% CI (0.742-1.159); p = 0.505; SG HR = 0.845, 95% CI (0.638-1.132); p = 0.265].

CONCLUSIONS

The degree of growth and maturation of scar tissue surrounding the lead was the strongest factor leading to the development of both types of ghosts. The presence of either form of ghost did not affect long-term survival even after TLE indicated for infection.

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.

Imaging of Cardiac Device-Related Infection

Cardiac devices are frequently used in different cardiovascular conditions for the purpose of morbidity or mortality prevention. These include cardiac implantable electronic devices (CIED) like permanent pacemakers and implantable cardiac defibrillators, ventricular assistance devices (VADs), left atrial appendage occlusion (LAAO) devices like the Watchman™, atrial and ventricular septal occluders like the Amplatzer™, among others. In the past years, there has been an increase in the development of these devices as a result of a rise in the number of indications for implantation, paired with the aging and more medically complex patient population. This has led to an increase in the incidence of cardiac device-related infections, one of the most feared and serious complications which is associated with significant morbidity, mortality and financial burden. Accurate diagnosis of cardiac device-related infections is essential given the management implications which often involve removal of the infected device, removal of other prosthetic material and long-term antimicrobial therapy. Clinical and laboratory data are useful diagnostic tools but multimodality imaging is often necessary. The recently published 2020 European Heart Rhythm Association International Consensus document, which is endorsed by many expert societies, has recommended the use of multimodality imaging for the diagnosis of CIED infections. (1) This allows better disease characterization by identifying abnormal fluid collections and guiding aspiration for both diagnostic and therapeutic purposes (i.e. soft tissue ultrasound and computed tomography), evaluation for local extent of disease (i.e. transesophageal echocardiogram to evaluate for concomitant infective endocarditis), embolic manifestation of disease (i.e. computed tomography and magnetic resonance imaging) and metabolic tissue characterization (positron emission tomography and tagged white blood cell scan). (2) In addition, computed tomography (CT) allows for pre-procedural planning which has shown to be associated with better procedural outcomes.

The role of transesophageal echocardiography in predicting technical problems and complications of transvenous lead extractions procedures

Background

Transesophageal echocardiography (TEE) is a useful tool in preoperative evaluation of patients undergoing transvenous lead extraction (TLE).

Hypothesis

Echocardiographic phenomena may determine the difficulty and safety of the procedure.

Methods

Data from 936 transesophageal examinations (TEE) performed at a high volume center in patients awaiting TLE from 2015 to 2019 were assessed.

Results

TEE revealed a total of 1156 phenomena associated with the implanted leads in 697 (64.85%) patients, including: asymptomatic masses on endocardial leads (AMEL) (58.65%), vegetations (12,73%), fibrous tissue binding the lead to the vein or heart wall (33.76%), lead‐to‐lead binding sites (18.38%), excess lead loops (19.34%), intramural penetration of the lead tip (16.13%) and lead‐dependent tricuspid dysfunction (LDTD) (6.41%). Risk factors for technical difficulties during TLE in multivariate analysis were: fibrous tissue binding the lead to atrial wall (OR = 1.738; p < 0.05), to right ventricular wall (OR = 2.167; p < 0.001), lead‐to‐lead binding sites (OR = 1.628; p < 0.01) and excess lead loops (OR = 1.488; p < 0.05). Lead‐to‐lead binding sites increased probability of major complications (OR = 3.034; p < 0.05). Presence of fibrous tissue binding the lead to the superior vena cava (OR = 0.296; p < 0.05), right atrial wall (OR = 323; p < 0.05) and right ventricular wall (OR = 0.297; p < 0.05) reduced the probability of complete procedural success, whereas fibrous tissue binding the lead to the tricuspid apparatus decreased the probability of clinical success (OR = 0.307; p < 0.05).

Conclusions

Careful preoperative TEE evaluation of the consequences of extended lead implant duration (enhanced fibrotic response) increases the probability of predicting the level of difficulty of TLE procedures, their efficacy and risk of major complications.

The prognostic value of transesophageal echocardiography after transvenous lead extraction: landscape after battle

Background

In patients undergoing transvenous lead extraction (TLE) transesophageal echocardiography (TEE) provide valuable information after procedure.

Methods

We analyzed data from 936 TEE performed in patients undergoing TLE between 2015 and 2019 (mean follow-up 566.23±224.47 days) and assessed the role of echocardiographic phenomena after procedure.

Results

Increment in tricuspid regurgitation (TR) was observed in 9% of patients after TLE. Factors increasing the risk of TR were: binding sites between lead and right ventricle (RV) (OR: 5.429), tricuspid valve (TV) (OR: 3.42), superior vena cava (SVC) (OR: 3.30) and lead-to-lead adhesions (OR: 2.88). Predisposing factors of residual structures after TLE were: asymptomatic masses on the leads (AMEL) (OR: 1.68), binding sites between SVC and cardiac structures (OR: 1.72), and multiple leads (OR: 1.30). Probability of vegetation remnants increased in the presence of abandoned leads (OR: 7.91). The risk factors of tamponade were: dwell time of the oldest lead (OR: 1.17), lead-to-lead adhesion (OR: 22.47), binding sites between lead and TV (OR: 6.08), RA (OR: 11.50), SVC (OR: 4.47), higher LVEF (OR: 2.35; P=0.006), female gender (OR: 5.43), multiple leads (OR: 2.11), looped leads (OR: 4.90) and AMEL (OR: 6.42). The risk of lead fracture was increased by: lead-to-lead adhesion (OR: 5.69), fibrosis binding the lead to RV (OR: 5.16), RA (OR: 2.39) and dwell time of the oldest lead (OR: 1.068). The mortality rate was 11.97% during follow-up. The risk of death was increased by: severe TR and vegetation remnants.

Conclusions

The most important phenomena evaluated after TLE are: tricuspid valve function, residual fibrosis and vegetation remnants, progression of pericardial effusion and retained lead fragments. Postoperative TEE provides information about the results of TLE and helps establish further management.

Prognostic Value of Preoperative Echocardiographic Findings in Patients Undergoing Transvenous Lead Extraction

(1) Background: In patients referred for transvenous lead extraction (TLE) transesophageal echocardiography (TEE) often reveals abnormalities related to chronically indwelling endocardial leads. The purpose of this study was to determine whether the results of pre-operative TEE might influence the long-term prognosis. (2) Methods: We analyzed data from 936 TEE examinations performed at a high volume center in patients referred for TLE from 2015 to 2019. The follow-up was 566.2 ± 224.5 days. (3) Results: Multivariate analysis of TEE parameters showed that vegetations (HR = 2.631 [1.738–3.983]; p < 0.001) and tricuspid valve (TV) dysfunction unrelated to the endocardial lead (HR = 1.481 [1.261–1.740]; p < 0.001) were associated with increased risk for long-term mortality. Presence of fibrous tissue binding sites between the lead and the superior vena cava (SVC) and/or right atrium (RA) wall (HR = 0.285; p = 0.035), presence of penetration or perforation of the lead through the cardiac wall up to the epicardium (HR = 0.496; p = 0.035) and presence of excessive lead loops (HR = 0.528; p = 0.026) showed a better prognosis. After adjustment the statistical model with recognized poor prognosis factors only vegetations were confirmed as a risk factor (HR = 2.613; p = 0.039). A better prognosis was observed in patients with fibrous tissue binding sites between the lead and the superior vena cava (SVC) and/or right atrium (RA) wall (HR = 0.270; p = 0.040). (4) Conclusions: Non-modifiable factors may have a negative influence on long-term survival after TLE. Various forms of connective tissue overgrowth and abnormal course of the leads modifiable by TLE can be a factor of better prognosis after TLE.

Echocardiographic findings in patients with cardiac implantable electronic devices-analysis of factors predisposing to lead-associated changes

BACKGROUND

The constant interaction between intracardiac leads and the heart and veins results in excessive accumulation of fibrous connective tissue around the leads. The extent of this pathological phenomenon, which is visible on transesophageal echocardiography (TEE), and predisposing factors are not well defined.

METHODS

We examined 936 transesophageal echocardiograms prior to transvenous lead extraction (TLE) performed at a high-volume centre between 2015 and 2019.

RESULTS

The most important echocardiographic findings were fibrous binding sites between leads and cardiovascular structures, lead-to-lead adhesions, excessive lead loops, lead-dependent tricuspid dysfunction (LDTD), asymptomatic masses on endocardial leads (AMEL) and vegetations. Fibrotic reaction within the walls of the heart and veins correlated with the presence of lead loops (OR = 1.771; p < .01) and lead dwell time (OR = 1.111; p < .001). Women were more likely to have excessive lead loops (OR = 1.639; p < .01), and the occurrence of loops increase with the number of implanted leads (OR = 2.557; p < .001). Heart failure (OR = 4.016; p < .001), lead looping (OR = 2.603; p < .01) and longer cumulative lead dwell time (OR = 1.017; p < .05) increased the likelihood of LDTD. A variety of AMEL were identified in this study, most commonly in patients with older leads (OR = 1.043; p < .001).

CONCLUSIONS

Lead dwell time is the main factor predisposing to the occurrence of most lead-associated phenomena visualized by TEE in patients with cardiac implantable electronic devices (CIED). Excessive looping of the lead is an important cause of fibrous binding sites and LDTD. AMEL are frequently detected in CIED patients, and their various forms concurrent with vegetations could represent an evolutionary stage of lead-associated masses.

European Heart Rhythm Association (EHRA) international consensus document on how to prevent, diagnose, and treat cardiac implantable electronic device infections-endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), the Latin American Heart Rhythm Society (LAHRS), International Society for Cardiovascular Infectious Diseases (ISCVID), and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS)

Pacemakers, implantable cardiac defibrillators, and cardiac resynchronization therapy devices are potentially lifesaving treatments for a number of cardiac conditions but are not without risk. Most concerning is the risk of a cardiac implantable electronic device (CIED) infection, which is associated with significant morbidity, increased hospitalizations, reduced survival, and increased health care costs. Recommended preventive strategies such as administration of intravenous antibiotics before implantation are well-recognized. Uncertainties have remained about the role of various preventive, diagnostic, and treatment measures such as skin antiseptics, pocket antibiotic solutions, antibacterial envelopes, prolonged antibiotics post-implantation, and others. When compared with previous guidelines or consensus statements, the present consensus document gives guidance on the use of novel device alternatives, novel oral anticoagulants, antibacterial envelopes, prolonged antibiotics post-implantation, as well as definitions on minimum quality requirements for centres and operators and volumes. The recognition that an international consensus document focused on management of CIED infections is lacking, the dissemination of results from new important randomized trials focusing on prevention of CIED infections, and observed divergences in managing device-related infections as found in an European Heart Rhythm Association worldwide survey, provided a strong incentive for a Novel 2019 International State-of-the-art Consensus document on risk assessment, prevention, diagnosis, and treatment of CIED infections.

European Heart Rhythm Association (EHRA) international consensus document on how to prevent, diagnose, and treat cardiac implantable electronic device infections-endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), the Latin American Heart Rhythm Society (LAHRS), International Society for Cardiovascular Infectious Diseases (ISCVID) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS)

Pacemakers, implantable cardiac defibrillators, and cardiac resynchronization therapy devices are potentially life-saving treatments for a number of cardiac conditions, but are not without risk. Most concerning is the risk of a cardiac implantable electronic device (CIED) infection, which is associated with significant morbidity, increased hospitalizations, reduced survival, and increased healthcare costs. Recommended preventive strategies such as administration of intravenous antibiotics before implantation are well recognized. Uncertainties have remained about the role of various preventive, diagnostic, and treatment measures such as skin antiseptics, pocket antibiotic solutions, anti-bacterial envelopes, prolonged antibiotics post-implantation, and others. Guidance on whether to use novel device alternatives expected to be less prone to infections and novel oral anticoagulants is also limited, as are definitions on minimum quality requirements for centres and operators and volumes. Moreover, an international consensus document on management of CIED infections is lacking. The recognition of these issues, the dissemination of results from important randomized trials focusing on prevention of CIED infections, and observed divergences in managing device-related infections as found in an European Heart Rhythm Association worldwide survey, provided a strong incentive for a 2019 International State-of-the-art Consensus document on risk assessment, prevention, diagnosis, and treatment of CIED infections.

European Heart Rhythm Association (EHRA) international consensus document on how to prevent, diagnose, and treat cardiac implantable electronic device infections-endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), the Latin American Heart Rhythm Society (LAHRS), International Society for Cardiovascular Infectious Diseases (ISCVID) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS)

Pacemakers, implantable cardiac defibrillators, and cardiac resynchronization therapy devices are potentially life-saving treatments for a number of cardiac conditions, but are not without risk. Most concerning is the risk of a cardiac implantable electronic device (CIED) infection, which is associated with significant morbidity, increased hospitalizations, reduced survival, and increased healthcare costs. Recommended preventive strategies such as administration of intravenous antibiotics before implantation are well recognized. Uncertainties have remained about the role of various preventive, diagnostic, and treatment measures such as skin antiseptics, pocket antibiotic solutions, anti-bacterial envelopes, prolonged antibiotics post-implantation, and others. Guidance on whether to use novel device alternatives expected to be less prone to infections and novel oral anticoagulants is also limited, as are definitions on minimum quality requirements for centres and operators and volumes. Moreover, an international consensus document on management of CIED infections is lacking. The recognition of these issues, the dissemination of results from important randomized trials focusing on prevention of CIED infections, and observed divergences in managing device-related infections as found in an European Heart Rhythm Association worldwide survey, provided a strong incentive for a 2019 International State-of-the-art Consensus document on risk assessment, prevention, diagnosis, and treatment of CIED infections.