Surgical Infections 2014.15:349-350. Downloaded from online.liebertpub.com by Uc Davis Libraries University of California Davis on 01/08/15. For personal use only.
SURGICAL INFECTIONS Volume 15, Number 3, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/sur.2013.084
Infectious Endocarditis Associated with a Permanent Pacemaker Lead Gabriel Pe´rez Baztarrica,1 Flavio Salvaggio,1 Flavio Rotryng,2 Norberto Blanco,3 Alejandro Botbol,3 and Rafael Porcile1
T
he incidence of infections of permanent pacemaker or cardioverter defibrillator leads is low. Treatment should include antibiotics and complete percutaneous or surgical removal of the device. Few data are available about the occurrence of infective endocarditis (IE) associated with permanent pacemaker leads with polymicrobial isolation, multiple vegetations, and the use of thoracotomy to remove the device. A 68-year-old female with a history of implantation of a dual-chamber demand (DDD) pacemaker 2 y previously, presenting with a prolonged febrile syndrome without an apparent focus. The pacemaker generator and the leads had been replaced 1 y earlier because of pacemaker pocket decubitus (abandoned ventricular lead). Physical examination at admission was normal. Laboratory test results showed leukocytosis with immature forms and an increased erythrocyte sedimentation rate (ESR). Blood cultures were positive initially for methicillin-resistant Staphylococcus aureus and later for Candida tropicalis. Infective endocarditis was suspected, and transesophageal echocardiography demonstrated several mobile, vegetations on the atrial and ventricular leads of her pacemaker (Fig. 1). With a confirmed diagnosis of pacemaker-related polymicrobial IE was implemented, but because the patient was pacemaker-dependent, and the size of the vegetations on her pacemaker leads made it impossible to perform a complete percutaneous removal of the device (with an abandoned lead in the right ventricle), an epicardial pacemaker was implanted via a thoracotomy with a right atriotomy (Fig. 2). After completing 6-wks of treatment with vancomycin and amphotericin B, at 28 mo of follow up showed no clinical signs of relapsing infection or other complications. According to different studies, the incidence of IE associated with implantable cardioverter-defibrillator (ICD) pacemakers ranges from 0.13% to almost 20% [1,2]. Diagnosis is based on a history of implantation associated with the clinical criteria for IE [2]. The two studies describing the incidences of IE recommend intravenous antibiotic treatment for 6 wk and complete removal of the ICD system. Antibiotic treatment alone or associated with partial extraction of the device has not proved effective, being followed by relapse or death [1,2].
Ordinarily, an ICD device can be removed percutaneously through the use of simple traction, sheaths, locking stylets, or laser sheaths. Although percutaneous extraction is favored in most circumstances because of the lower associated morbidity and mortality, it cannot be used for all lead extractions. Transvenous extraction of an ICD device has been associated with minimal morbidity and mortality [3]. If this approach is not feasible (either because of the size of a vegetation, an indication for concomitant cardiac surgery, or technical difficulties), the device can be removed through sternotomy and atriotomy with the use of cardiopulmonary bypass [1]. However, this more invasive approach has a higher rate of complications [4]. The size of the vegetation indicating the method of removal of an ICD is controversial, with some authors believing that vegetations larger than 10 mm are a relative contraindication to the transvenous removal of pacemaker leads because of the risk of pulmonary embolism, and others having found that with vegetations exceeding
FIG. 1. Transesophageal echocardiogram showing multiple, mobile, and irregular images compatible with vegetations on the atrial and ventricular leads of the patient’s pacemaker, with the largest such vegetation measuring 25 · 8 mm.
Faculties of 1Cardiology, 2Infectology, and 3Cardiovascular Surgery, Faculty of Medicine, Hospital of the Universidad Abierta Interamericana, Buenos Aires, Argentina.
349
350
BAZTARRICA ET AL. paradoxical embolism, and the impossibility of complete percutaneous removal of the device.
Surgical Infections 2014.15:349-350. Downloaded from online.liebertpub.com by Uc Davis Libraries University of California Davis on 01/08/15. For personal use only.
References
FIG. 2. Photograph of the surgical procedure done on the patient, showing one of the vegetations adherent to the atrial catheter of her pacemaker. 20 mm, the risk of embolism is high but neither mortality nor hospitalization was increased in this setting [5]. We decided to perform thoracotomy in the case because of the impossibility of achieving complete removal of the patient’s device through a percutaneous approach. Percutaneous removal of a definitive pacemaker and implantable cardioverter defibrillator leads is the first choice of treatment for IE associated with such instrumentation. Open heart surgery is a good alternative in certain cases, such as concomitant heart surgery, multiple vegetations or vegetations larger than 3 cm, atrial septal defect with the risk of
1. Sohail M, Uslan D, Khan A, et al. Management and outcome of permanent pacemaker and implantable cardioverterdefibrillator infections. J Am Coll Cardiol. 2007;49:1851–1859. 2. Baddour L, Epstein A, Erickson C, et al. Update on cardiovascular implantable electronic device infections and their management: A scientific statement from the American Heart Association. Circulation 2010;121:458–477. 3. Jones IV S, Eckart R, Albert C, et al. Large, single-center, single-operator experience with transvenous lead extraction: Outcomes and changing indications. Heart Rhythm 2008;5: 520–525. 4. Rusanov A, Spotnitz H. A 15-year experience with permanent pacemaker and defibrillator lead and patch extrations. Ann Thorac Surg 2010;89:44–50. 5. Pe´rez Baztarrica G, Gariglio L, Salvaggio F, et al. Transvenous extraction of pacemaker leads in infective endocarditis with vegetations ‡ 20 mm: Our experience. Clin Cardiol 2012;4: 244–249.
Address correspondence to: Dr. Gabriel Pe´rez Baztarrica Department of Cardiology Faculty of Medicine Hospital of the Universidad Abierta Interamericana Portela 2975(1437) Buenos Aires, Argentina E-mail: [email protected]
SURGICAL INFECTIONS Volume 15, Number 3, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/sur.2013.084
Infectious Endocarditis Associated with a Permanent Pacemaker Lead Gabriel Pe´rez Baztarrica,1 Flavio Salvaggio,1 Flavio Rotryng,2 Norberto Blanco,3 Alejandro Botbol,3 and Rafael Porcile1
T
he incidence of infections of permanent pacemaker or cardioverter defibrillator leads is low. Treatment should include antibiotics and complete percutaneous or surgical removal of the device. Few data are available about the occurrence of infective endocarditis (IE) associated with permanent pacemaker leads with polymicrobial isolation, multiple vegetations, and the use of thoracotomy to remove the device. A 68-year-old female with a history of implantation of a dual-chamber demand (DDD) pacemaker 2 y previously, presenting with a prolonged febrile syndrome without an apparent focus. The pacemaker generator and the leads had been replaced 1 y earlier because of pacemaker pocket decubitus (abandoned ventricular lead). Physical examination at admission was normal. Laboratory test results showed leukocytosis with immature forms and an increased erythrocyte sedimentation rate (ESR). Blood cultures were positive initially for methicillin-resistant Staphylococcus aureus and later for Candida tropicalis. Infective endocarditis was suspected, and transesophageal echocardiography demonstrated several mobile, vegetations on the atrial and ventricular leads of her pacemaker (Fig. 1). With a confirmed diagnosis of pacemaker-related polymicrobial IE was implemented, but because the patient was pacemaker-dependent, and the size of the vegetations on her pacemaker leads made it impossible to perform a complete percutaneous removal of the device (with an abandoned lead in the right ventricle), an epicardial pacemaker was implanted via a thoracotomy with a right atriotomy (Fig. 2). After completing 6-wks of treatment with vancomycin and amphotericin B, at 28 mo of follow up showed no clinical signs of relapsing infection or other complications. According to different studies, the incidence of IE associated with implantable cardioverter-defibrillator (ICD) pacemakers ranges from 0.13% to almost 20% [1,2]. Diagnosis is based on a history of implantation associated with the clinical criteria for IE [2]. The two studies describing the incidences of IE recommend intravenous antibiotic treatment for 6 wk and complete removal of the ICD system. Antibiotic treatment alone or associated with partial extraction of the device has not proved effective, being followed by relapse or death [1,2].
Ordinarily, an ICD device can be removed percutaneously through the use of simple traction, sheaths, locking stylets, or laser sheaths. Although percutaneous extraction is favored in most circumstances because of the lower associated morbidity and mortality, it cannot be used for all lead extractions. Transvenous extraction of an ICD device has been associated with minimal morbidity and mortality [3]. If this approach is not feasible (either because of the size of a vegetation, an indication for concomitant cardiac surgery, or technical difficulties), the device can be removed through sternotomy and atriotomy with the use of cardiopulmonary bypass [1]. However, this more invasive approach has a higher rate of complications [4]. The size of the vegetation indicating the method of removal of an ICD is controversial, with some authors believing that vegetations larger than 10 mm are a relative contraindication to the transvenous removal of pacemaker leads because of the risk of pulmonary embolism, and others having found that with vegetations exceeding
FIG. 1. Transesophageal echocardiogram showing multiple, mobile, and irregular images compatible with vegetations on the atrial and ventricular leads of the patient’s pacemaker, with the largest such vegetation measuring 25 · 8 mm.
Faculties of 1Cardiology, 2Infectology, and 3Cardiovascular Surgery, Faculty of Medicine, Hospital of the Universidad Abierta Interamericana, Buenos Aires, Argentina.
349
350
BAZTARRICA ET AL. paradoxical embolism, and the impossibility of complete percutaneous removal of the device.
Surgical Infections 2014.15:349-350. Downloaded from online.liebertpub.com by Uc Davis Libraries University of California Davis on 01/08/15. For personal use only.
References
FIG. 2. Photograph of the surgical procedure done on the patient, showing one of the vegetations adherent to the atrial catheter of her pacemaker. 20 mm, the risk of embolism is high but neither mortality nor hospitalization was increased in this setting [5]. We decided to perform thoracotomy in the case because of the impossibility of achieving complete removal of the patient’s device through a percutaneous approach. Percutaneous removal of a definitive pacemaker and implantable cardioverter defibrillator leads is the first choice of treatment for IE associated with such instrumentation. Open heart surgery is a good alternative in certain cases, such as concomitant heart surgery, multiple vegetations or vegetations larger than 3 cm, atrial septal defect with the risk of
1. Sohail M, Uslan D, Khan A, et al. Management and outcome of permanent pacemaker and implantable cardioverterdefibrillator infections. J Am Coll Cardiol. 2007;49:1851–1859. 2. Baddour L, Epstein A, Erickson C, et al. Update on cardiovascular implantable electronic device infections and their management: A scientific statement from the American Heart Association. Circulation 2010;121:458–477. 3. Jones IV S, Eckart R, Albert C, et al. Large, single-center, single-operator experience with transvenous lead extraction: Outcomes and changing indications. Heart Rhythm 2008;5: 520–525. 4. Rusanov A, Spotnitz H. A 15-year experience with permanent pacemaker and defibrillator lead and patch extrations. Ann Thorac Surg 2010;89:44–50. 5. Pe´rez Baztarrica G, Gariglio L, Salvaggio F, et al. Transvenous extraction of pacemaker leads in infective endocarditis with vegetations ‡ 20 mm: Our experience. Clin Cardiol 2012;4: 244–249.
Address correspondence to: Dr. Gabriel Pe´rez Baztarrica Department of Cardiology Faculty of Medicine Hospital of the Universidad Abierta Interamericana Portela 2975(1437) Buenos Aires, Argentina E-mail: [email protected]
