Venous thoracic outlet syndrome, as a pitfall for cardiac implantable electronic device implantations

The subclavian vein is typically used in cardiovascular implantable electronic device (CIED) implantations. External stress on the subclavian vein can lead to lead-related complications. There are several causes of this stress, such as frequent upper extremity movements or external injury. Venous thoracic outlet syndrome (TOS) can also become the cause of external lead stress. However, the diagnosis of venous TOS can be challenging because subclavian venography can appear normal at first glance. We present a unique case of a device infection in a patient with venous TOS. A careful observation of the imaging studies is vital for diagnosing venous TOS and a leadless pacemaker implantation could be an alternative therapeutic option.

Comparison of infection and complication rates associated with transvenous vs. subcutaneous defibrillators in patients with stage 4 chronic kidney disease: a multicenter long-term retrospective follow-up

Background

Patients with progressive chronic kidney disease (CKD) are at higher risk of infections and complications from cardiac implantable electronic devices (CIED). In patients with a primary or secondary prophylactic indication, implantable cardiac defibrillators (ICD) can prevent sudden cardiac deaths (SCD). We retrospectively compared transvenous-ICD (TV-ICD) and intermuscularly implanted subcutaneous-ICD (S-ICD) associated infections and complication rates together with hospitalizations in recipients with stage 4 kidney disease.

Methods

We retrospectively analyzed 70 patients from six German centers with stage 4 CKD who received either a prophylactic TV-ICD with a single right ventricular lead, 49 patients, or a S-ICD, 21 patients. Follow-Ups (FU) were performed bi-annually.

Results

The TV-ICD patients were significantly older. This group had more patients with a history of atrial arrhythmias and more were prescribed anti-arrhythmic medication compared with the S-ICD group. There were no significant differences for other baseline characteristics. The median and interquartile range of FU durations were 55.2 (57.6-69.3) months. During FU, patients with a TV-ICD system experienced significantly more device associated infections (n = 8, 16.3% vs. n = 0; p < 0.05), device-associated complications (n = 13, 26.5% vs. n = 1, 4.8%; p < 0.05) and device associated hospitalizations (n = 10, 20.4% vs. n = 1, 4.8%; p < 0.05).

Conclusion

In this long-term FU of patients with stage 4 CKD and an indication for a prophylactic ICD, the S-ICD was associated with significantly fewer device associated infections, complications and hospitalizations compared with TV-ICDs.

18F-FDG PET/CT in left ventricular assist device infections: In-depth characterization and clinical implications

BACKGROUND

Previous retrospective studies suggest a good diagnostic performance of 18F-fluorodeoxyglucose positron emission tomography (18F-FDG-PET)/computed tomography (CT) in left ventricular assist device (LVAD) infections. Our aim was to prospectively evaluate the role of PET/CT in the characterization and impact on clinical management of LVAD infections.

METHODS

A total of 40 patients (aged 58 [53-62] years) with suspected LVAD infection and 5 controls (aged 69 [64-71] years) underwent 18F-FDG-PET/CT. Four LVAD components were evaluated: exit site and subcutaneous driveline (peripheral), pump pocket, and outflow graft. The location with maximal uptake was considered the presumed site of infection. Infection was confirmed by positive culture (exit site or blood) and/or surgical findings.

RESULTS

Visual uptake was present in 40 patients (100%) in the infection group vs 4 (80%) control subjects. For each individual component, the presence of uptake was more frequent in the infection than in the control group. The location of maximal uptake was most frequently the pump pocket (48%) in the infection group and the peripheral components (75%) in the control group. Maximum standard uptake values (SUVmax) were higher in the infection than in the control group: SUVmax (average all components): 6.9 (5.1-8.5) vs 3.8 (3.7-4.3), p = 0.002; SUVmax (location of maximal uptake): 10.6 ± 4.0 vs 5.4 ± 1.9, p = 0.01. Pump pocket infections were more frequent in patients with bacteremia than without bacteremia (79% vs 31%, p = 0.011). Pseudomonas (32%) and methicillin-susceptible Staphylococcus aureus (29%) were the most frequent pathogens and were associated with pump pocket infections, while Staphylococcus epidermis (11%) was associated with peripheral infections. PET/CT affected the clinical management of 83% of patients with infection, resulting in surgical debridement (8%), pump exchange (13%), and upgrade in the transplant listing status (10%), leading to 8% of urgent transplants.

CONCLUSIONS

18F-FDG-PET/CT enables the diagnosis and characterization of the extent of LVAD infections, which can significantly affect the clinical management of these patients.

Unique Extraction of a Fractured Pacemaker Lead Adhered to the Spermatic Vein

Transvenous lead extraction has been increasingly recognized as a safe and effective method of lead extraction, but there are only few references for extracting leads migrating outside the heart. We present a successful extraction of a fractured pacemaker lead from the spermatic vein using several approaches and multiple tools.

Case Report: A leadless and endovascular pacemaker teamwork

Background

Cardiac Implantable Electronic Device infections increase short- and long-term mortality, along with healthcare costs. Leadless pacemakers (PM) were developed to overcome pocket- and minimize lead-related complications in selected high-risk patients. Recent advancements enable leadless devices to mechanically detect atrial activity, facilitating atrioventricular (AV) synchronous stimulation.

Case summary

A 90-year-old woman, implanted with a dual-chamber pacemaker eight years ago due to sinus node dysfunction, presented with syncope. A diagnosis of complete AV block, in the setting of ventricular lead dysfunction was made. Due to a high risk of infection, the patient was implanted with a leadless PM capable of maintaining AV synchrony in VDD mode (MICRA™ model MC1AVR1). The transvenous PM was programmed to AAI-R mode to drive the atria, which, in turn, triggered the leadless PM to stimulate the ventricles. At six month follow-up, the AV synchrony rate was 85%.

Conclusion

The combination of classic atrial pacing with leadless ventricular stimulation can be used in high-risk patients to reduce the risk of complications, in the setting of ventricular lead dysfunction. In this manner, AV synchrony can be maintained, improving hemodynamic parameters and quality of life. Low sinus rate variability at rest is essential to achieve a high AV synchrony rate in such cases.

Long-Term Outcomes of Transvenous Lead Extraction: A Comparison in Patients with or without Infection from the Italian Region with the Oldest Population

BACKGROUND

The gold standard for the treatment of cardiac implantable electronic devices (CIEDs)-related infection and lead malfunction is transvenous lead extraction (TLE). To date, the risk of mortality directly related to TLE procedures is relatively low, but data on post-procedural and long-term mortality are limited, even more in the aging population.

METHODS

Consecutive patients with CIEDs who underwent TLE were retrospectively studied. The primary outcome was the endpoint of death, considering independent predictors of long-term clinical outcomes in the TLE aging population comparing patients with and without infection.

RESULTS

One hundred nineteen patients (male 77%; median age 76 years) were included in the analysis. Eighty-two patients (69%) documented infection, and thirty-seven (31%) were extracted for a different reason. Infected patients were older (80 vs. 68 years, p-value > 0.001) with more implanted catheters (p-value < 0.001). At the last follow-up (FU) available (median FU 4.1 years), mortality reached 37% of the patient population, showing a statistically significant difference between infected versus non-infected groups. At univariable analysis, age at TLE, atrial fibrillation, and anemia remained significant correlates of mortality; at multivariable analysis, only patients with anemia and atrial fibrillation have a 2.3-fold (HR 2.34; CI 1.16-4.75) and a 2.5-fold (HR 2.46; CI 1.33-4.54) increased rate of death, respectively.

CONCLUSION

Our long-term data showed that aging patients who underwent TLE for CIED-related infection exhibit a high mortality risk during a long-term follow-up, potentially leading to a rapid and effective procedural approach in this patient population.

Petechial Rash and Glomerulonephritis: First Presentation of Endocarditis on a Patent Foramen Ovale Closure Device

Patent foramen ovale device closure is rarely associated with complications. This case report is believed to be the first description of a patient with infective endocarditis of a patent foramen ovale closure device presenting as glomerulonephritis. This article serves to educate as to this rare device complication and its unusual presentation. (Level of Difficulty: Intermediate.).

The Year in Electrophysiology: Selected Highlights From 2022

This special article is the fifth in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors would like to thank the Editor-in-Chief, Dr Kaplan, the Associate Editor-in-Chief, Dr Augoustides, and the editorial board for the opportunity to author this series, which summarizes the key research papers in the electrophysiology (EP) field relevant to cardiothoracic and vascular anesthesiologists. These articles are shaping perioperative EP procedures and practices, such as pulsed-field ablation, cryoablation for first-line treatment for atrial fibrillation, advancements in conduction system pacing, safety issues related to smartphones and cardiac implantable electronic devices, and alterations in EP workflow as the world emerges from the COVID-19 pandemic. Special emphasis is placed on the implications of these advancements for the anesthetic care of patients undergoing EP procedures.

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.

Impact of Narrowing Perioperative Antibiotic Prophylaxis for Left Ventricular Assist Device Implantation

BACKGROUND

Although infections are a significant potential complication among patients undergoing left ventricular assist device (LVAD) implantation, standardized surgical infection prophylaxis (SIP) regimens are not well defined. At Montefiore Medical Center, a 4-drug SIP regimen containing fluconazole, ciprofloxacin, rifampin, and vancomycin was previously utilized. In January 2020, the antimicrobial stewardship program implemented a 2-drug SIP regimen of vancomycin and cefazolin to limit exposure to broad-spectrum antibiotics. This study evaluated LVAD-associated infection rates prior to and following the SIP revision.

METHODS

A retrospective review of patients who underwent LVAD implantation from 1/2018-4/2021 was performed. Infections were classified using the International Society for Heart and Lung Transplantation definitions. Infection rates at 2 weeks, 30 days, and 90-days post-implantation in the 4-drug SIP regimen (1/2018-12/2019) and the 2-drug SIP regimen (1/2020-4/2021) were compared.

RESULTS

A total of 71 patients were included. The number of patients with LVAD-associated infections (including surgical site infections) was not significantly different in either SIP group at 2 weeks (9% vs 4%, p = 0.64), 30 days (9% vs 11%, p = 0.99), or 90 days (19% vs 14%, p = 0.75). There was no statistically significant difference in 30 or 90-day mortality. LVAD-associated gram-negative (7% vs 7%; p>0.99) and fungal (5% vs 0%; p = 0.51) infections were uncommon. The most common organism isolated was Staphylococcus aureus and the most common type of infection was pneumonia in both SIP groups.

CONCLUSION

No significant difference in LVAD-associated infections or infection-related mortality was observed with de-escalation of perioperative antibiotics. Additional studies with larger sample sizes are needed to endorse the findings of this study. This article is protected by copyright. All rights reserved.

Factors Related to the Skin Thickness of Cardiovascular Implantable Electronic Device Pockets

BACKGROUND

The skin overlying cardiovascular implantable electronic devices (CIEDs) sometimes becomes very thin after implantations, which could cause a device erosion. The factors related to the skin thickness of device pockets have not been elucidated.

OBJECTIVE

This study aimed to evaluate the skin thickness of CIED pockets and search for the factors associated with the thickness.

METHODS

Seventeen skin thickness points around the CIED pocket were measured through ultrasonography in each patient.

RESULTS

A total of 101 patients (76±11 years, 26 female) was enrolled. The median duration from the implantation to the examination was 95 months (quartile: 52.5~147.5). The median skin thickness overlying the device was 4.1 mm (3.3~5.9). Patients with heart failure and malignancy had thinner skin overlying the CIED than those without. A significant correlation existed between skin thickness and body mass index (BMI), hemoglobin, serum creatinine, estimated glomerular filtration rate (eGFR), and left ventricular ejection fraction. In contrast, the age, gender, and device size did not exhibit a significant correlation with the skin thickness. A multivariate logistic regression analysis revealed that chronic heart failure and a decrease in the eGFR and BMI were independent predictive factors of "very thin (≦3.3 mm)" skin of the CIED pocket late after an implantation.

CONCLUSION

Aside from a low BMI, the comorbidities (low hemoglobin, heart failure, and renal dysfunction) had a stronger impact on the skin thickness overlying the device than the device size. A careful observation of the device pocket should be performed in patients with those risk factors. This article is protected by copyright. All rights reserved.

Impact of Timing of Transvenous Lead Removal on Outcomes in Infected Cardiac Implantable Electronic Devices

BACKGROUND

Cardiovascular implantable electronic device (CIED) infections are associated with increased mortality and morbidity.

OBJECTIVE

This study sought to evaluate the impact of early versus delayed transvenous lead removal (TLR) on in-hospital mortality and outcomes in patients with CIED infection.

METHODS

Using the nationally representative, all-payer, Nationwide Readmissions Database, we evaluated patients undergoing TLR for CIED infection between January 1, 2016, to December 31, 2018. The timing of the TLR procedure was determined based on hospitalization days after initial admission for CIED infection. The impact of early (≤ 7 days) versus delayed (> 7 days) TLR on mortality and major adverse events was studied.

RESULTS

Of 12,999 patients who underwent TLR for CIED infections, 8,834 patients underwent early TLR versus 4,165 patients who underwent delayed TLR. Delayed TLR was associated with a significant increase in in-hospital mortality (8.3% vs. 3.5%, adjusted odds ratio:1.70; 95% confidence interval, 1.43-2.03; P value<0.001). Subgroup analysis of patients with CIED infection and systemic infection showed that delayed TLR in patients with systemic infection was associated with a higher rate of in-hospital mortality compared with early TLR (10.4% vs. 7.5%, adjusted odds ratio:1.24; 95% confidence interval, 1.04-1.49; P value<0.019). Delayed TLR was also associated with significantly higher adjusted odds of major adverse events and post-procedural length of stay.

CONCLUSIONS

These data suggest that delayed transvenous lead removal in patients with CIED infections is associated with increased in-hospital mortality and major adverse events, especially in patients with systemic infection.

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 effect of a standardised protocol for CIED insertion on complications and infection rates in a DGH

Cardiac implantable electronic device (CIED)-related complications and infections typically lead to prolonged hospital stays and, very occasionally, death. A new CIED insertion protocol was implemented in a district general hospital. The primary objective of this study was to determine whether a significant reduction in complication and infection rates occurred after implementation of the new protocol. Medical records were reviewed for patients who had a CIED inserted in the two years pre- and post-protocol implementation, and any complications were identified in a one-year follow-up period. An increase in the complexity of the devices implanted after introduction of the protocol was observed. The number of complications was significantly reduced from 6.86% to 3.95% (p<0.0001). In the two years prior to protocol implementation, 14 of 871 (1.6%) patients suffered a CIED-related infection. In contrast, four of 683 (0.44%) patients suffered a CIEDrelated infection in the two years postimplementation. This was not statistically significant (p=0.093). In conclusion, implementing a standardised protocol for CIED insertion significantly reduced the rate of complications, and also reduced the rate of infection, but this was not statistically significant.

A Review of Cardiac Implantable Electronic Device Infections for the Practicing Electrophysiologist

Cardiovascular implantable electronic device (CIED) infections are morbid, costly, and difficult to manage. This review explores the pathophysiology, diagnosis, and management of CIED infections. Diagnostic accuracy has been improved through increased awareness and improved imaging strategies. Pocket or bloodstream infection with virulent organisms often requires complete system extraction. Emerging prophylactic interventions and novel devices have expanded preventative strategies and options for re-implantation. A clear and nuanced understanding of CIED infection is important to the practicing electrophysiologist.

Risk Factors for Repeat Infection and Mortality After Extraction of Infected Cardiovascular Implantable Electronic Devices

OBJECTIVES

This study sought to investigate the factors associated with repeat infection following lead extraction procedures.

BACKGROUND

Although lead extraction is an essential therapy for patients with cardiovascular implantable electronic device (CIED) infection, repeat infection still occurs in some patients.

METHODS

The authors reviewed data for consecutive patients who underwent extraction of infected CIEDs from August 2003 to May 2019. Repeat infection was defined as infective endocarditis, sepsis with no alternative focus, or pocket infection after extraction of infected CIEDs.

RESULTS

Extraction of infected CIEDs was performed in 496 patients. The most commonly implicated pathogen was Staphylococcus aureus (188 patients). In 449 patients (90.5%), all leads were completely extracted using only transvenous techniques. Thirty-three patients (6.7%) underwent surgical lead extraction, and 14 (2.8%) had retained leads or lead components. After a median follow-up of 352 [40 to 1,255] days after CIED extraction, 144 patients (29.0%) died. Repeat infection occurred in 47 patients (9.5%) with the median time from the extraction to repeat infection of 103 [45 to 214] days. In multivariable analysis, presence of a left ventricular assist device, younger age at extraction, and S. aureus infection were independent predictors of repeat infection. Additionally, chronic kidney disease, congestive heart failure, presence of septic emboli, S. aureus infection, and occurrence of major complications were independent predictors of increased mortality.

CONCLUSIONS

Patients with S. aureus infection have a high risk of repeat infection and poor prognosis after CIED extraction. Repeat infection is also predicted by younger age and the presence of a left ventricular assist device, whereas mortality was predicted by congestive heart failure, chronic kidney disease, and septic emboli.

Case Report: 18F-FDG PET-CT for Diagnosing Prosthetic Device-Related Infection in an Infant With CHD

Patients who have undergone cardiac surgery using prosthetic devices have an increased risk of developing prosthetic device-related infection and mediastinitis. However, accurate diagnosis of prosthetic device-related infection can be difficult to evaluate and treat with antibiotic therapy alone. In recent years, ¹⁸F-fluorodeoxyglucose positron emission tomography-computed tomography (¹⁸F-FDG PET-CT) has made promising contributions to detect infective endocarditis, pacemaker infections, or other inflammations. Nevertheless, ¹⁸F-FDG PET-CT for congenital heart disease (CHD) with device infection has been sparsely reported. We present an infantile girl diagnosed with pulmonary atresia with a ventricular septal defect who underwent replacement of the right ventricle-to-pulmonary artery (RV-PA) conduit for improvement cyanosis. She developed high fever and was diagnosed with mediastinitis and bacteremia by Pseudomonas aeruginosa (P. aeruginosa) on postoperative day 4. Mediastinal drainage and 6 weeks of antibiotic therapy improved her condition, but bacteremia flared up on postoperative day 56. Despite a long course of antibiotic therapy, she had two more recurrences of bacteremia with the detection of P. aeruginosa. Echocardiography and chest contrast CT showed no evidence of vegetation and mediastinitis. On postoperative day 115, ¹⁸F-FDG PET-CT revealed an accumulation on the RV-PA conduit (SUV max 3.4). Finally, she developed an infectious ventricular pseudo-aneurysm on postoperative day 129 and underwent aneurysm removal and RV-PA conduit replacement on postoperative day 136. Our case showed the importance of ¹⁸F-FDG PET-CT for diagnosing specific localization of prosthetic device-related infection which is hard to detect using other imaging techniques. It can be a useful diagnostic tool for infantile patients with CHD with cardiac prosthetic devices and improve subsequent clinical treatments.

Counter incision is a safe and effective method for alternative reservoir placement during inflatable penile prosthesis surgery

Background

Alternative reservoir placement is increasingly popular during inflatable penile prosthesis (IPP) surgery to prevent intraperitoneal positioning, bowel, bladder, or vascular injury in patients with prior pelvic surgeries. Counter incision (CI) can be used for submuscular reservoir placement in high risk patients, however series exploring the safety remain limited.

Methods

A database of IPP surgeries was queried for use of a CI during reservoir placement to compare 90-day clinical outcomes in a retrospective case-control study. Primary outcome was device infections, with secondary outcomes including reservoir herniation, hematoma, device malfunction rates, and operative times. Groups were compared using Kruskal-Wallis and Chi-Squared tests, with multivariate logistic regression models to identify predictors of infectious complications.

Results

A total of 534 cases met criteria, of which 51 (9.6%) used a CI for reservoir placement. The CI cohort included significantly more removal and replacements, 45.1% vs. 20.9% (P<0.001). Thirty-one CI patients (61.0%) had undergone prior prostatectomy compared to 134 (27.7%) non-CI patients (P=0.001). The most common reasons for CI were prior prostatectomy and inguinal hernia repair. Median operative time was 17 minutes longer in the CI group (74 vs. 57 minutes, P<0.001). Device infection rates were similar (2.0% vs. 4.1%, P=0.71), as were rates of hematoma (5.9% vs. 2.7%, P=0.19), and device malfunction (0.0% vs. 1.4% P=1.00).

Conclusions

Complication rates were similar between CI and non-CI cohorts, even in a subset where approximately half the cases were removal and replacements. For physicians not comfortable with alternative placement through a penoscrotal or infrapubic incision, this offers a reasonable alternative and permits use of three-piece devices in patients with a hostile pelvis.

Infectious and Sterile Endophthalmitis in Eyes with Glaucoma Drainage Device from Two Large Ophthalmic Institutions

PURPOSE

To describe the predisposing factors, presentation, management, and outcome of glaucoma drainage implant (GDI)-associated endophthalmitis.

DESIGN

Retrospective chart review.

PARTICIPANTS

Eyes that developed GDI-associated endophthalmitis between December 1, 2011, and December 23, 2019, at the Duke Eye Center and Cole Eye Institute.

METHODS

Patient data search was performed on the basis of diagnostic codes for GDI and endophthalmitis. Endophthalmitis was defined clinically according to each physician's discretion. Eyes with infection source other than GDI were excluded. Worse vision was defined as a decrease of more than 2 Snellen lines. Data were collected on baseline demographics, systemic and ocular comorbidities, ocular surgical history, best-corrected visual acuity (BCVA), intraocular pressure (IOP), clinical presentation, eye culture results, and treatments performed. Statistical analysis included the paired t test and odds radio calculations.

MAIN OUTCOME MEASURES

Visual acuity and IOP at final follow-up.

RESULTS

Thirty cases (0.7%) of GDI endophthalmitis were identified among 4073 GDIs performed at the 2 institutions with active follow-up. Device exposure was identified in 20 eyes (67%) on presentation. The average follow-up after presentation was 22.4 ± 25 months. The most frequently identified organism on culture was Streptococcus pneumoniae. Same-day injection of intravitreal antibiotics was the universal first-line therapy. From baseline to final follow-up, the mean BCVA decreased from -0.84 ± 0.77 to -1.30 ± 0.93 (logarithm of the minimum angle of resolution, P = 0.02). Mean IOP did not change from baseline to final visit in the overall cohort (16.2 ± 8.2 mmHg to 14.6 ± 9.4 mmHg, P = 0.30) and in the subgroup that underwent tube explant (15.9 ± 5.5 mmHg to 15.2 ± 10.4 mmHg, P = 0.97). Eighteen of 20 tube exposure cases (90%) underwent tube explant, 1 underwent tube revision, and 1 re-epithelialized.

CONCLUSIONS

Glaucoma drainage implant-associated endophthalmitis was correlated with poor visual outcome. Immediate intravitreal antibiotic delivery was a universal first-line therapy. Tube exposure was a necessary risk factor for late-onset endophthalmitis and required surgical removal or repair.

Surgical infection prophylaxis prior to left ventricular assist device implantation: A survey of clinical practice

BACKGROUND

Short duration, antimicrobial prophylaxis that includes antistaphylococcal activity is recommended at the time of left ventricular assist device (LVAD) implantation to reduce infection-related complications. There continues to be wide variability in surgical infection prophylaxis (SIP) regimens among implantation centers. The aim of this study is to characterize current SIP regimens at different LVAD centers.

METHODS

A survey study was conducted from 26 September 2017 to 25 October 2017. Surveys were distributed electronically to LVAD coordinators and infectious diseases specialists at 75 US medical centers identified as having an LVAD program. Data collection included information about antimicrobial selection, duration, Staphylococcus aureus screening, and decolonization procedures.

RESULTS

We received 29 survey responses. The majority of surveys were completed by infectious diseases physicians (72.4% [21 out of 29]). Most responding centers reported LVAD programs established for greater than 10 years (20 out of 29 [69%]). Cardiac transplantation was performed in 28 out of 29 (96%) centers. Of centers reporting a defined SIP regimen for non-penicillin allergic patients (96% [28 out of 29]), 17.9% (5 out of 28) reported a four-drug regimen, 35.7% (10 out of 28) reported a three-drug regimen, and 46.4% (13 out of 28) reported a two-drug regimen, while no centers reported a single-drug regimen. Empiric fluconazole was common (50% [14 out of 28]) and 96.4% (27 out of 28) of regimens included vancomycin. Duration of antimicrobial prophylaxis (24 hours to 5 days), S. aureus screening, decolonization procedures, and alterations due to drug allergies varied across participating centers.

CONCLUSIONS

Our survey results indicate wide variation in SIP regimens among participating LVAD centers. These results highlight the need for studies evaluating the implications of SIP regimens, and whether clinical factors that prolong antimicrobial duration impact postoperative infection rates.

18F-FDG PET/CT in Left-Ventricular Assist Device Infection: Initial Results Supporting the Usefulness of Image-Guided Therapy

Accurate definition of the extent and severity of left-ventricular assist device (LVAD) infection may facilitate therapeutic decision making and targeted surgical intervention. Here, we explore the value of ¹⁸F-FDG PET/CT for guidance of patient management. Methods: Fifty-seven LVAD-carrying patients received 85 whole-body ¹⁸F-FDG PET/CT scans for the work-up of device infection. Clinical follow-up was obtained for up to 2 y. Results: PET/CT showed various patterns of infectious involvement of the 4 LVAD components: driveline entry point (77% of patients), subcutaneous driveline path (87%), pump pocket (49%), and outflow tract (58%). Driveline smears revealed Staphylococcus or Pseudomonas strains as the underlying pathogen in most cases (48 and 34%, respectively). At receiver-operating-characteristic analysis, an ¹⁸F-FDG SUV of more than 2.5 was most accurate to identify smear-positive driveline infection. Infection of 3 or all 4 LVAD components showed a trend toward lower survival than did infection of 2 or fewer components (P = 0.089), whereas involvement of thoracic lymph nodes was significantly associated with an adverse outcome (P = 0.001 for nodal SUV above vs. below median). Finally, patients who underwent early surgical revision within 3 mo after PET/CT (n = 21) required significantly less inpatient hospital care during follow-up than did those receiving delayed surgical revision (n = 11; P < 0.05). Conclusion: Whole-body ¹⁸F-FDG PET/CT identifies the extent of LVAD infection and predicts adverse outcome. Initial experience suggests that early image-guided surgical intervention may facilitate a less complicated subsequent course.

Ventricular assist device-related infections and solid organ transplantation-Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

The Infectious Diseases Community of Practice of the American Society of Transplantation has published evidenced-based guidelines on the prevention and management of infectious complications in SOT recipients since 2004. This updated guideline reviews the epidemiology of ventricular assist device (VAD) infections and provides recommendations for the management and prevention of these infections. Almost one half of those awaiting heart transplantation are supported with VADs. Despite advances in device technologies, VAD infections commonly complicate mechanical circulatory support and remain typified by common components and anatomic locations. These infections have important implications for transplant candidates, most notably increased wait-list mortality. Strategic management of these infections is crucial for successful transplantation. Coincidentally, explantation of all VAD components at the time of transplantation is often the definitive cure for the device-associated infection. Highlighted in this updated guideline is the reported success of transplantation in patients with a variety of pre-existing VAD infections and guidance on post-transplant management strategies.

Successful percutaneous retrieval of a micra transcatheter pacing system at 8 weeks after implantation

An 86-year-old woman suffering from repeated methicillin-resistant Staphylococcus aureus (MRSA) bacteremia underwent percutaneous lead extraction using an excimer laser. Since negative blood cultures were confirmed three times after lead extraction under intravenous infusion of anti-MRSA drugs, a Micra transcatheter pacing system (Micra TPS) was implanted 7 days after the lead extraction. Although infusion of anti-MRSA drugs was continued for 5 weeks, MRSA was isolated in four separate samples of blood cultures 3 weeks after the discontinuation of the anti-MRSA therapy. The micra TPS was successfully retrieved using a steerable sheath and snare at 8 weeks after implantation.

AngioVac Debulking in Endocarditis Patients with Large, Device-related Vegetations

As the number and complexity of cardiovascular implantable electronic devices has increased, so too has the incidence of device-related infections. Such a rise requires that the focus be directed toward developing universal standards for infected lead removal. To date, no consensus currently exists regarding the optimal management of patients with large vegetations (diameter > 2 cm). In these individuals, medical therapy is universally ineffective and they are often too ill for surgical extraction; furthermore, transvenous lead extraction (TLE) carries with it a risk of large septic pulmonary emboli. We present a series of five cases in which the AngioVac thrombectomy system (AngioDynamics Inc., Latham, NY, USA) was used as an adjunct to TLE. Debridement of infected leads prior to percutaneous lead extraction was accomplished as either a bridge to or as concomitant therapy with laser lead removal at our institution. This study included three males and two females with an average age of 52 years. The sizes of vegetations removed from leads ranged from 1.5 cm to 3.9 cm in the largest dimension and the average diameter was 2.65 cm ± 1.1 cm. The vegetations were successfully debulked in all five patients. This suggests that TLE performed with assistance from the AngioVac system (AngioDynamics Inc., Latham, NY, USA) is a safe and effective alternative to open surgical lead removal in patients with large lead vegetations.

Reimplantation and Repeat Infection After Cardiac-Implantable Electronic Device Infections: Experience From the MEDIC (Multicenter Electrophysiologic Device Infection Cohort) Database

BACKGROUND

Infection is a serious complication of cardiovascular-implantable electronic device implantation and necessitates removal of all hardware for optimal treatment. Strategies for reimplanting hardware after infection vary widely and have not previously been analyzed using a large, multicenter study.

METHODS AND RESULTS

The MEDIC (Multicenter Electrophysiologic Device Infection Cohort) prospectively enrolled subjects with cardiovascular-implantable electronic device infections at multiple institutions in the United States and abroad between 2009 and 2012. Reimplantation strategies were evaluated overall, and every patient who relapsed within 6 months was individually examined for clinical information that could help explain the negative outcome. Overall, 434 patients with cardiovascular-implantable electronic device infections were prospectively enrolled at participating centers. During the initial course of therapy, complete device removal was done in 381 patients (87.8%), and 220 of them (57.7%) were ultimately reimplanted with new devices. Overall, the median time between removal and reimplantation was 10 days, with an interquartile range of 6 to 19 days. Eleven of the 434 patients had another infection within 6 months, but only 4 of them were managed with cardiovascular-implantable electronic device removal and reimplantation during the initial infection. Thus, the repeat infection rate was low (1.8%) in those who were reimplanted. Patients who retained original hardware had a 11.3% repeat infection rate.

CONCLUSIONS

Our study findings confirm that a broad range of reimplant strategies are used in clinical practice. They suggest that it is safe to reimplant cardiac devices after extraction of previously infected hardware and that the risk of a second infection is low, regardless of reimplant timing.

Cardiac Implantable Electronic Device Infections: Added Complexity and Suboptimal Outcomes With Previously Abandoned Leads

OBJECTIVES

This study sought to assess the impact of previously abandoned leads on the clinical management of cardiac device infections, notably transvenous lead extraction and subsequent clinical course.

BACKGROUND

The population of patients with cardiac implantable electronic devices continues to grow with a disproportionate increase in device infections, which are invariably life threatening. A potentially complicating issue is the widely practiced strategy of device lead abandonment at the time of system revision, change, or upgrade, which is affecting an increasing number of patients.

METHODS

The study assessed the impact of previously abandoned leads in a prospectively maintained registry of consecutive patients undergoing percutaneous extraction of infected cardiac devices at the Cleveland Clinic between August 1996 and September 2012. The primary clinical endpoint was complete procedural and clinical success defined as the successful removal of the device and all lead material from the vascular space, in the absence of a major complication.

RESULTS

Of 1,386 patients with infected cardiac devices, 323 (23.3%) had previously abandoned leads. Failure to achieve the primary endpoint occurred more frequently in patients with abandoned leads (13.0% vs. 3.7%; p < 0.0001). This was primarily due to retention of lead material (11.5% vs. 2.9%; p < 0.0001), which was associated with poor clinical outcomes including higher rates of 1-month mortality (7.4% vs. 3.5% in those without lead remnants). Lead extraction procedures in patients with previously abandoned leads were longer (p < 0.0001), with longer fluoroscopy times (p < 0.0001), and more likely to require specialized extraction tools (94.4% vs. 81.8%; p < 0.0001) or adjunctive rescue femoral workstations (14.9% vs. 2.9%; p < 0.0001). Procedural complications occurred more frequently in patients with previously abandoned leads (11.5% vs. 5.6%; p = 0.0003), which was true for both major (3.7% vs. 1.4%; p = 0.009) and minor complications (7.7% vs. 4.4%; p = 0.02).

CONCLUSIONS

Previously abandoned leads complicate the management of cardiac device infections, leading to worse clinical outcomes.

The major autolysin is redundant for Staphylococcus aureus USA300 LAC JE2 virulence in a murine device-related infection model

The major Staphylococcus aureus autolysin, Atl, has been implicated in attachment to surfaces and release of extracellular DNA during biofilm formation under laboratory conditions. Consistent with this, polyclonal antibodies to the amidase and glucosaminidase domains of Atl inhibited in vitro biofilm formation. However, in a murine model of device-related infection the community-associated S. aureus strain USA300 LAC JE2 established a successful infection in the absence of atl These data indicate that Atl activity is not required for biofilm production in this infection model and reveal the importance of characterizing the contribution of biofilm phenotypes to virulence under in vivo conditions.

Success With Extended-Infusion Meropenem After Recurrence of Baclofen Pump-Related Achromobacter Xylosoxidans Meningitis in an Adolescent

A 13-year-old female experienced a recurrence of baclofen pump-related central nervous system (CNS) infection caused by Achromobacter, despite absence of retained foreign material. Due to the failure of meropenem (120 mg/kg/d in divided doses every 8 hours and infused over 30 minutes) in the initial infection, the dose was infused over 4 hours during the recurrence. Meropenem is an antibiotic for which efficacy is time dependent, and 4-hour versus 30-minute infusions have been shown to prolong the time the concentration of the antibiotic exceeds the minimum inhibitory concentration (MIC) of the organism at the site of infection (T>MIC). Meropenem serum concentrations were obtained and indicated that T>MIC was at least 75% of the dosing interval. Our patient improved with no noted recurrences or adverse effects on the extended-infusion meropenem regimen. Utilization of extended-infusion beta-lactam dosing whenever possible in the treatment of serious infections caused by gram-negative organisms should be considered, as this dosing appears to be safe and improves the probability of achieving pharmacokinetic/pharmacodynamic goals.

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.

Survival of patients with biventricular devices after device infection, extraction, and reimplantation

OBJECTIVES

This study sought to compare outcomes in patients with biventricular device infections who undergo successful treatment including extraction and reimplantation to patients with biventricular devices never known to become infected.

BACKGROUND

Infection of a cardiac implantable electronic device (CIED) is associated with substantial morbidity and mortality. Survival in patients with cardiac resynchronization therapy (CRT) device infections undergoing full system extraction is unknown.

METHODS

We extracted data on all patients undergoing extraction of a biventricular pacing device for an infectious indication at the Cleveland Clinic between February 16, 2000, and June 30, 2011. Survival of patients who presented with a CRT device infection, extraction, and successful reimplantation was compared to that of a large cohort of consecutive patients undergoing initial CRT implantation without a known history of subsequent device-related infection. In addition, long-term outcomes were compared between patients who were extracted and deemed to be cured with and without successful biventricular device reimplantation.

RESULTS

In all, 151 patients underwent biventricular device extraction for infection, of whom 81 were successfully reimplanted. The noninfected cohort consisted of 879 patients. In a multivariate Cox regression model controlling for sex, a history of ischemic cardiomyopathy, creatinine, hemoglobin, beta-blocker use, angiotensin-converting enzyme inhibitor use, and diuretic use, no significant association between subsequent infection with reimplantation and all-cause mortality was noted (p = 0.21). There was a trend toward worse outcomes for patients extracted, deemed cured, and not reimplanted compared to patients with successful CRT reimplantation.

CONCLUSIONS

Patients with a biventricular device infection who are successfully extracted, treated with antibiotics, and reimplanted with a biventricular device have outcomes similar to those of patients with biventricular devices not known to have become infected.

Staphylococcal biofilm-forming protein has a contiguous rod-like structure

Staphylococcus aureus and Staphylococcus epidermidis form communities (called biofilms) on inserted medical devices, leading to infections that affect many millions of patients worldwide and cause substantial morbidity and mortality. As biofilms are resistant to antibiotics, device removal is often required to resolve the infection. Thus, there is a need for new therapeutic strategies and molecular data that might assist their development. Surface proteins S. aureus surface protein G (SasG) and accumulation-associated protein (S. epidermidis) promote biofilm formation through their "B" regions. B regions contain tandemly arrayed G5 domains interspersed with approximately 50 residue sequences (herein called E) and have been proposed to mediate intercellular accumulation through Zn(2+)-mediated homodimerization. Although E regions are predicted to be unstructured, SasG and accumulation-associated protein form extended fibrils on the bacterial surface. Here we report structures of E-G5 and G5-E-G5 from SasG and biophysical characteristics of single and multidomain fragments. E sequences fold cooperatively and form interlocking interfaces with G5 domains in a head-to-tail fashion, resulting in a contiguous, elongated, monomeric structure. E and G5 domains lack a compact hydrophobic core, and yet G5 domain and multidomain constructs have thermodynamic stabilities only slightly lower than globular proteins of similar size. Zn(2+) does not cause SasG domains to form dimers. The work reveals a paradigm for formation of fibrils on the 100-nm scale and suggests that biofilm accumulation occurs through a mechanism distinct from the "zinc zipper." Finally, formation of two domains by each repeat (as in SasG) might reduce misfolding in proteins when the tandem arrangement of highly similar sequences is advantageous.

Modeling of fungal biofilms using a rat central vein catheter

Candida frequently grows as a biofilm, or an adherent community of cells protected from both the host immune system and antimicrobial therapies. Biofilms represent the predominant mode of growth for many clinical infections, including those associated with placement of a medical device. Here, we describe a model for Candida biofilm infection of one important clinical niche, a venous catheter. This animal model system incorporates the anatomical site, immune components, and fluid dynamics of a patient venous catheter infection and can be used for study of biofilm formation, drug resistance, and gene expression.