Treatment of Cardiac Device Infections
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- Kory White
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1 Treatment of Cardiac Device Infections Peter Ammann
2 yrs old patient Pocket infection after pacemaker change. Staph. aureus growing in blood cultures. Pacemaker dependent. Echo: no vegetations on valves or leads A) local surgical revision and AB treatment B) complete extraction of system and transvenous reimplantation after negative blood cultures C) complete extraction of system and epicardial system
3 3 88 yrs old patient Pocket infection after pacemaker change. Staph. aureus growing in blood cultures. Pacemaker dependent. Echo: no vegetations on valves or leads A) local surgical revision and AB treatment B) complete extraction of system and transvenous reimplantation after negative blood cultures C) complete extraction of system and epicardial system
4 4 Complete device and lead removal is recommended for all patients with definite CIED infection, as evidenced by valvular and/or lead endocarditis or sepsis. Class 1 Level of Evidence: A ESC, AHA, ACC Guidelines 2010
5 5 Number of end organ failures per 1000 recipients of CIED by year of implantation Voigt PACE 2010
6 6 4.7% risk of death and USD cost per device infection Greenspon et al J Am Coll Cardiol 2011
7 7 Risk factors for CIED infections Early reintervetion OR=15.04 Long term steroid use OR =13.9 Fever within 24h before impl. OR=5.8 Renal dysfunktion (GFR<60ml/min/m2) OR=4.8 Preprocedural pacing OR=2.4 device changes (ERI) OR=2.4 Diabetes, Anticoagulation Lekkerkerker et al Heart 2009 Klug et al Circulation 2008
8 8 Infection rates after CRT implnatations/box changes Unsworth et al Europace 2015
9 9 70 yrs old man after CRT-D pocket change 5 yrs after implantation
10 10 53 yrs old man after ICD implantation
11 11 Sohail et al JACC 07
12 12 What do you think is mortality rate 2 years after device extraction? A <5 % B 5-10% C 10-20% D 20-30%
13 13 Long term mortality after transvenous lead removal Survival probability at 2 yrs 84.3% Maytin et al Circ Arrthm Electrophysiol 2012
14 14 How to reduce infections???????????
15 15 Operating room versus EP laboratory? Data from 667 ICD implantations Remmelts et al Neth Heart J 2009
16 16 Prevention of infection
17 17 Pre Implantation Correct 3 min hand disinfection Preoperative skin washing with chlorhexidin gluconate 4% solution night before and morning before implantation strict 3 min dry time before surgical skin preparation with chlorhexidin gluconate 2% and isopropyl alcohol at time of implantation Study by Koeberl et al Circulation 2011;124:A10041 in 3874 pts (2622 before and 1251 after) Reduction of Infection 1% to 0.24% (HR 4.2) 6/18/2015 Referent / Bereich
18 Antibiotics before implantation? Only one RCT: Cephazolin i.v. vs Placebo Study stopped prematurely after inclusion of 649 patients (planed 1000) 91% brady-devices; 53% device change 13 infections: 2 vs 11 (RR 19 p=0.016) De Oliveira Circ Arrythima Electophysiol 2009
19 PACE day oral cephalexin or clindamycin
20 Under investigation: Treatment of cardiac device infections antibacterial envelope (TYRX) biocompatible mesh coated with minocycline/rifampicin that elute within 7-10 days
21 HRS 2015
22 22
23 23
24 24
25 25 presented at HRS 2015 Boston
26 26
27 Future will go leadless and subcutaneous
28 28 Recurrence after complete 29 infections extraction: rejected 7/354= 1.9% 29 no extraction 3 deaths before extraction 16 deaths 354 success 425 patients 396 infections definite or possible 381 extractions Mortality: 6.3% with extraction: 5% Recurrence without complete extraction 10/23= 43% 6 incomplete extract. 5 failure without extraction: 17% Lille experience courtesy Prof Klug People study Circulation no extraction Infection recurrence Death with infectious process
29 29 Treatment: extraction Prospective study 425 patients/381 extractions FU months 1. Transoesophageal echocardiography Vegetation Size <20 mm Percutaneous extraction Failure >20 mm Surgical extraction Surgical procedure refused or jugged too risky Antimicrobial treatment
30 30 Percutaneous vs surgical extraction Percutaneous extraction: 337 patients. Surgical extraction 44 patients (16%) second intention after failure of percutaneous extraction in 10 patients. Procedure related death occurred in 14 patients: 3 cardiac or vena cava injuries 9 septic shocks 2 pulmonary embolisms 1 patient deceased of an associated mitral valve endocarditis, and 1 pts deceased at day 4 of ventricular tachycardia. A new device was implanted in 244 patients (64%!), transvenous leads in 132 and epicardial leads in 112
31 31 Risk of septic or embolic death according to Thrombus/Vegetation size P=0.03
32 32 Antimicrobial treatment Extraction procedure If blood cultures negative, empirical antistaphylococcal therapy Drug regimen modified according the lead cultures results. intravenously orally weeks If pacing dependent epicardial pacing system If not pacing dependent re-evaluation and endocardial reimplantation if required
33 33 Rochester Algorithm
34 34 Time of re-implantation: Rochester experience retrospective analysis of 189 CDI Sohail et al. J Am Coll Cardiol 2007
35 LifeVest von Zoll Treatment of cardiac device infections
36 36
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