Search Results (14)

Background and Objectives: Cardiac implantable electronic device (CIED) infections remain among the most serious complications of pacemaker, implantable cardioverter-defibrillator, and cardiac resynchronization therapy procedures. They are associated with substantial morbidity, mortality, prolonged hospitalization, system extraction, long-term antimicrobial therapy, and increased healthcare costs. As most infections arise from perioperative contamination or procedure-related complications, prevention has become a major priority in contemporary electrophysiology practice. This review aimed to summarize current evidence on the prevention of CIED infections, with particular emphasis on modifiable risk factors and perioperative preventive measures. Materials and Methods: A focused narrative review was undertaken using targeted searches of PubMed/MEDLINE and Scopus, supplemented by major international guideline and consensus documents, with priority given to contemporary guidelines, randomised trials, meta-analyses, and major observational studies relevant to CIED infection prevention. Results: Prevention of CIED infection requires a structured, multifactorial approach spanning the entire procedural pathway. Key preventive strategies include careful reassessment of device indication, individualized device selection, correction of modifiable risk factors, postponement of elective implantation in the presence of active infection, appropriate perioperative antibiotic prophylaxis, and optimized management of anticoagulant and antiplatelet therapy to minimize pocket hematoma. Additional relevant measures include meticulous skin antisepsis, limitation of temporary invasive devices and unnecessary hardware, appropriate venous access selection, careful generator pocket creation and wound closure, and avoidance of early reintervention whenever feasible. Antibacterial envelopes may reduce major CIED infections in selected high-risk patients, whereas routine escalation of preventive measures without proven benefit is not supported. Conclusions: CIED infection prevention is inherently multifactorial and depends on the consistent application of evidence-based measures before, during, and after device implantation. Rigorous control of modifiable risk factors, prevention of pocket hematoma, appropriate antimicrobial prophylaxis, and meticulous procedural technique remain the cornerstones of effective infection prevention in patients undergoing CIED procedures. Full article

Background: Globalization, increased mobility, changes in dietary habits, and a growing number of immunocompromised patients have heightened exposure to rare or opportunistic pathogens. Here, we present a case of cardiac implantable electronic device-related infective endocarditis (CIED-IE) caused by Bacillus cereus bacteremia originating in the gastrointestinal tract. Case presentation: A 66-year-old female, who had a cardiac resynchronization pacemaker (CRT-P) implanted in 2017 due to second-degree atrioventricular block and left bundle branch block, had undergone device replacement due to battery depletion 4 months earlier and was scheduled for transvenous lead extraction (TLE) due to generator pocket infection. During the TLE procedure, transoesophageal echocardiography revealed vegetations on the leads and in the right atrium. Standard empirical therapy covering methicillin-resistant Staphylococci and Gram-negative bacteria was administered, including oritavancin and gentamicin. Surprisingly, intraoperative samples cultured B. cereus, a Gram-positive, spore-forming rod that usually causes food poisoning through contamination of rice and other starchy foods. B. cereus is generally resistant to β-lactam antibiotics except for carbapenems but is susceptible to glycopeptides. The oritavancin treatment was extended to four fractionated doses (1200, 800, 800, and 800 mg) administered at 7-day intervals. To eradicate bacteria in the gastrointestinal tract, oral vancomycin (125 mg 4 times a day) was added. After 4 weeks of effective antibiotic therapy, a CRT-P with a left bundle branch area pacing lead was reimplanted on the right subclavian area, with no recurrence of infection during the 3-month follow-up. Clinical discussion: In the patient, a diet high in rice and improper storage of rice dishes, together with habitual constipation, were identified as risk factors for the development of invasive Bacillus cereus infection. However, the long half-life lipoglycopeptide antibiotic, oritavancin, administered weekly, proved effective in treating CIED-IE. Conclusions: Infection with rare or opportunistic microorganisms may require extended microbiological diagnostics and non-standard antibiotic therapy; therefore, the medical history should consider risk factors for such infections. Full article

Background: Cardiac implantable electronic device (CIED) infections necessitate extraction and subsequent pacing interventions. Conventional methods after removing the infected CIED system involve temporary or semi-permanent pacing followed by delayed permanent pacemaker (PPM) implantation. Leadless pacemakers (LPs) may offer an alternative, allowing immediate PPM implantation without increasing infection risks. Our objective is to evaluate the safety and cost-effectiveness of LP implantation during the same procedure of CIED extraction, compared to conventional two-stage approaches. Methods: Pacemaker-dependent patients with systemic or pocket infection undergoing device extraction and LP implantation during the same procedure at Sheba Medical Center, Israel, were compared to a historical group of patients undergoing a semi-permanent (SP) pacemaker implantation during the procedure, followed by a permanent pacemaker implantation. Results: The cohort included 87 patients, 45 undergoing LP implantation and 42 SP implantation during the extraction procedure. The LP group demonstrated shorter intensive care unit stay (1 ± 3 days vs. 7 ± 12 days, p < 0.001) and overall hospital days (11 ± 24 days vs. 17 ± 17 days, p < 0.001). Rates of infection relapse and one-year mortality were comparable between groups. Economic analysis revealed comparable total costs, despite the higher initial expense of LPs. Conclusions: LP implantation during CIED extraction offers significant clinical and logistical advantages, including reduced hospital stays and streamlined treatment, with comparable safety and cost-effectiveness to conventional approaches. Full article

Background and Objectives: The number of cardiac pacemakers being used has increased in recent decades, and this increase has led to a rise in device-related complications, requiring percutaneous device extraction. Our aim was to present our single-center clinical experience in percutaneous lead extractions. Materials and Methods: We analyzed an observational retrospective cohort study of 93 patients for the transvenous removal of a total of 163 endocardial leads. We evaluated the device details, indications, lead characteristics, extraction methods, complications, reimplantation procedure, follow-up data, effectiveness, and safety. Results: Patients’ mean age was 68.6 ± 11.6 years. Lead extraction indications were pocket infection in 33 (35.5%), lead dysfunction in 33 (35.5%), and system upgrade in 21 (23%) cases, and lead endocarditis in 6 (6%) cases. The duration from implantation to extraction time was a detected median of 43 (24–87) months. The most common retracted lead type was the RV defibrillator lead (62%), and the lead fixation type was active for one hundred (61%) patients. A new device was inserted in 74 (80%) patients, and the device type was most commonly a CRT-D (61%). Patients were followed up at a median of 17 (8–36) months, and 18 patients (19%) died at follow-up. Complete procedural success was obtained in 78 (84%) patients, and clinical procedural success was obtained in 83 (89%) patients. Procedural failure was detected in 15 (16%) patients. Major and minor complications were detected in 10 (11%) and 6 (6.5%) patients, respectively. The most common minor complication was pocket hematoma. Conclusions: Our experience suggests that transvenous lead extraction has a high success rate with an acceptable risk of procedural complications. The simple manual traction method has a high rate of procedural success, despite a high dwell time of the lead. Full article

Indications for cardiac implantable electronic devices (CIEDs) are increasing. Almost one-third of device-related infections are endocarditis. Transvenous lead extraction (TLE) has emerged as an effective and safe approach for treating device-related infections and complications. Multiple types of extraction tools are being used worldwide. Our goal is to evaluate the safety and effectiveness of TLE using non-powered extraction tools. The study included patients between October 2018 and July 2022 requiring TLE according to EHRA expert consensus recommendations on lead extraction. A total of 88 consecutive patients were included. Indications for TLE included device-related infections in 74% of the patients. Of those, 32% had device-related endocarditis with or without sepsis. Staphylococcus Aureus was the most frequent pathogen in patients with endocarditis and positive bacteremia, and 57% had negative bloodstream cultures. A total of 150 cardiac pacing and defibrillator leads were targeted for extraction. The mean dwell time for leads was 6.92 ± 4.4 years; 52.8% were older than 5 years, 15.8% were older than ten years, and the longest lead dwell time was 26 years. Patients’ age varied between 18 and 98, with a mean age of 66 ± 16 years. Sixty-seven percent of patients were males. Using only non-powered extraction tools, we report 93.3% complete lead removal and 99% clinical success with partial extraction. We report no procedure-related death nor major complications. Minor complication incidence was 6.8%, and all complications resolved spontaneously. The 30-day mortality rate was 3.4%. TLE using non-powered extraction tools is safe and effective even without surgical backup on site. Full article

Infective endocarditis (IE) is a disease of the endocardium, which leads to the appearance of vegetation on the valves, cardiac structures, or, potentially, vascular endothelium of the heart. The risk of IE can be increased more than 140 times by congenital heart disease (50–59% of all IE), particularly if cyanotic. An increase in mortality may result from IE in patients with a complex cardiac pathology or patients with an implanted prosthetic material, most frequently conduits in a pulmonary position. Cardiac implantable electronic devices (CIED) infective endocarditis is a life-threatening complication representing 10% of all cases of endocarditis. Common signs of presentation are often fever and chills; redness and swelling at the pocket of the pacemaker, including the erosion and exteriorization of the device; and life-threatening sepsis. The use of intracardiac echocardiography for the diagnosis of IE is an innovative method. This may be needed, especially in older children undergoing complex cardiac surgery, when transthoracic echocardiography (TTE) and transesophageal echocardiography (TOE) failed to provide a reliable diagnosis. The 2018 European Heart Rhythm Association (EHRA) experts’ consensus statement on transvenous lead extraction recommends complete device removal and antimicrobial therapy for any device-related infection, including CIED-IE. The most detected microorganism was Staphylococcus Aureus. In addition, cardiac surgery and interventional cardiology associated with the placement of prostheses or conduits may increase the risk of IE up to 1.6% for Melody valve implantation. Our manuscript presents a comprehensive review of infective endocarditis associated with cardiac devices and prostheses in the pediatric population, including recent advances in diagnosis and management. Full article

Leadless pacemakers (LPMs) have emerged as an alternative to conventional transvenous pacemakers to eliminate the complications associated with leads and subcutaneous pockets. However, LPMs still present with complications, such as cardiac perforation, dislodgment, vascular complications, infection, and tricuspid valve regurgitation. Furthermore, the efficacy of the leadless VDD LPMs is influenced by the unachievable 100% atrioventricular synchrony. In this article, we review the available data on the strategy selection, including appropriate patient selection, procedure techniques, device design, and post-implant programming, to minimize the complication rate and maximize the efficacy, and we summarize the clinical settings in which a choice must be made between VVI LPMs, VDD LPMs, or conventional transvenous pacemakers. In addition, we provide an outlook for the technology for the realization of true dual-chamber leadless and battery-less pacemakers. Full article

There are no data on procedure-related bleeding outcome with non-vitamin K antagonist anticoagulants (NOACs) versus vitamin K antagonist anticoagulants (VKAs) in patients with atrial fibrillation (AF) undergoing cardiac implantable electronic device (CIED) intervention. Our aim was to evaluate whether NOACs have a safety benefit even in terms of fewer hemorrhagic complications at the site of CIED implant. Consecutive AF patients receiving NOACs or VKAs at the time of CIED procedure were included in this observational, retrospective, and monocentric investigation. Primary endpoint was the incidence of post-intervention pocket hematoma. A total of 311 patients were enrolled, 146 on NOACs, and 165 on VKAs. The incidence of pocket hematoma was 3.4% in the NOAC versus 13.3% in the VKA group (p = 0.002). Primary outcome-free survival at 30-days was 96.6% in patients on NOACs and 86.0% in those on VKAs (p = 0.019). Multivariate analysis, adjusted by propensity-score calculation of inverse-probability-weighting, showed a significantly lower occurrence of pocket hematoma in patients receiving NOACs versus VKAs (HR 0.35, 95% CI 0.13–0.96, p = 0.042). Such NOACs benefit was confirmed versus patients on VKAs without peri-procedural bridging with low-molecular-weight heparin (HR 0.34, 95% CI 0.11–0.99, p = 0.048). The incidence of pocket infection, surgical pocket evacuation, ischemic events, and major bleeding complications at 30 days (secondary endpoints) was similar in the two groups. In conclusion, our data suggest that, among patients with AF undergoing implantable cardiac defibrillator or pacemaker intervention, the use of NOACs versus VKAs may be associated with significant reduction of post-procedural pocket hematoma, regardless of bridging with low-molecular-weight heparin in the VKA group. These results are hypothesis generating and need to be confirmed in a specific randomized study. Full article

We present the first case of implantation of a novel singlechamber leadless pacemaker capable of atrioventricular (AV) synchronous pacing in a patient with COVID-19 and complete AV block. This device not only promotes AV synchrony, but also eliminates risk of iatrogenic pneumothorax and pocket complications, such as haematoma and infection and may therefore be considered a valuable alternative to a dual-chamber pacemaker. Full article

A five-month-old African jenny was presented with a history of exercise intolerance and syncopal episodes. Severe bradycardic arrhythmia due to a high-grade second-degree atrioventricular (AV) block with progression to complete AV block was diagnosed. The jenny underwent a transvenous single-chamber pacemaker implantation. The implantation procedure was performed in a lateral recumbency and the ventricular lead was inserted through the jugular vein. Positioning of the lead was guided by echocardiography. The pacemaker was programmed to VVI mode with a minimal ventricular rate of 40 pulses per minute, a pulse amplitude of 2.4 V, a pulse width of 0.5 ms and sensing amplitude of 2.5 mV. Short-term complications associated with the procedure included lead dislodgement and pacemaker pocket infection. The long-term outcome was satisfactory; the jenny showed improvement in heart function and quality of life after pacemaker implantation. The pulse generator replacement was performed twice (at nine-year intervals) and the intervention was always associated with a local inflammatory reaction around the pacing device. Cardiac examination 18 years after pacemaker implantation revealed no morphological changes in the heart; the electrode lead was still in the correct position and successful pacing and sensing of the ventricle were obtained. Regular follow-up checks are important to evaluate pacemaker function. Full article

Lead pacemaker infection is a complication on the rise. An infected oscillating mass attached to the leads (ILV) is a common finding in this setting. Percutaneous extraction of the leads and of the device is the best curative option. However, extraction of leads with large masses can be complicated by pulmonary embolism. The aim of this study was to understand the factors associated with large ILV using a sophisticated ultrasound technique to visualize the masses, namely intracardiac echocardiography (ICE), and investigate whether larger masses induce more complications during and after extraction. Percutaneous lead extraction and peri-procedural ICE were done in 36 patients (pts) (75 ± 11 years old, 74% males). Vegetations (max dimension = 8.2 ± 4.1 mm) in the right cavity were found in 26 of them, mostly adhering to the leads. We subdivided the patients into 2 groups: with vegetation size < 1 cm (18 pts) and vegetation size ≥ 1 cm (8 pts). By univariate analysis, we found that patients in group 1 were more often taking anticoagulation therapy (p = 0.03, Phi (Phi coefficient) = −0.5, OR [odds ratio] 0.071) and had signs of local pocket infection (p = 0.02, Phi = −0.52, OR 0.059) while significantly more patients in group 2 had diabetes (p = 0.08, Phi = 0.566, OR 15); moreover the patients in group 2 showed a trend toward a more frequent positive blood culture (p = 0.08, Phi = 0.39, OR 5.8) and infection with coagulase negative staphylococci (p = 0.06, Phi = 0.46, OR 8.3). At multivariate analysis, only 3 factors (diabetes, younger age and anticoagulation therapy) were independently associated with ILV size: diabetes, associated with larger vegetations (group 2), showed the largest beta value (0.44, p = 0.008); age was inversely correlated with ILV size (beta value = −32, p = 0.038), and anticoagulation therapy (beta value = −029, p = 0.048) was more commonly associated with smaller vegetations (group 1). Larger ILV were not associated with more complications or death during or after the extraction. Conclusion: diabetes, anticoagulation therapy and age are independent predictors of lead vegetation size. The embolic potential of large ILV during extraction was modest, so ILVs >1cm are not a contraindication to percutaneous extraction of infected leads. Full article

Mycobacterium goodii has only rarely been reported to cause invasive disease in humans. Previously reported cases of M. goodii infection have included prosthetic joint infections, pacemaker pocket infections, and pneumonia. We present a case of bacteremia with concomitant pulmonary septic emboli that developed in a 32-year-old woman with an indwelling central line. The line had been placed one year previously for intermittent treatment with intravenous, broad-spectrum antibiotics, administered by an outside physician for the treatment of symptoms attributed to chronic Lyme disease. The long duration of antibiotic use and presence of a central venous catheter predisposed the patient to this infection. Patients should be counseled regarding the serious risks of long courses of broad-spectrum intravenous antibiotics via central venous catheters to treat non-specific symptoms attributed to Lyme disease. Full article

Retraction of device leads may be a risky procedure. We report a case of a patient with a pacemaker pocket infection and two abandoned leads. Locking stylets were introduced in each electrode and both stylets were pulled through the rotating blade with simultaneous retraction and rotation of the blade. This technique allowed successful liberation of both leads at once. Full article

This article gives an overview on the practical management of device infections of chronically implanted pacemakers and implantable cardioverter- defibrillators. The main feature of such infections is the fact that the implanted materials have direct contact with the bloodstream, and therefore, may rapidly progress to systemic infection with serious septic complications. Apart from aggressive antibiotic treatment, in general, the infected material has to be explanted. Therefore, it is helpful to differentiate between the isolated pocket infection with the option of local surgical revision under preservation of the implanted leads and the systemic infection with the necessity of complete removal of all implanted materials using either the lead-extraction technique or open heart surgery. Full article