pacemaker and lead infections alpay celiker md. hacettepe university ankara, turkey case based...
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Pacemaker and Lead Infections
Alpay Celiker MD.Hacettepe University
Ankara, Turkey
Case Based TutorialCase Based TutorialHeart Rhythm 2006. May 17-20 Boston, USAHeart Rhythm 2006. May 17-20 Boston, USA
Heart Rhythm 2006. May 17-20 Boston, USA
Birth1988
September 1990Surgery for FT
June 1994VVIR Transvenous Pace
September 2000Battery Change
September 1990VVI Epicardial Pace
Abandoned Lead RemovalInsertion of a new lead
April 2001Lead Fracture
February 2005Fever
Sensing&CaptureProblem
Case ReportCase Report
Heart Rhythm 2006. May 17-20 Boston, USA
Clinical Findings
•History: −Fever−Chills−Vomiting−Blurred vision−Artralgia
•Physical Examination−Fever: 380 C−Pulse: 100 bpm, BP: 110/70 mm Hg−Grade 2-3/6 systolic ejection murmur−Mild early diastolic murmur−No local sign of infection
Heart Rhythm 2006. May 17-20 Boston, USA
Heart Rhythm 2006. May 17-20 Boston, USA
Laboratory I
• Hb: 13 gr/dl• WBC: 27000 /mm3
• Differential count: Unremarkable• Platelet: 198.000/mm3
• ESR: 10 mm/hour, CRP: 5.4 mg/dl• Normal renal and liver function tests• Urine: Trace protein, fine granular
cylinders
Heart Rhythm 2006. May 17-20 Boston, USA
Laboratory II
• Blood Culture (Several times): Negative
• Brain CT: Normal
• Transthoracic Echo: Bad echo window−TR: Grade II, V: 3.2 m/second−Pulmonary Gradient 16 mm Hg−Pacemaker electrodes in right ventricle
cavity−No visible thrombus or vegetation
Heart Rhythm 2006. May 17-20 Boston, USA
Treatment
Vancomycine Gentamycine
(7 days)
Persisting Fever
CeftriaxoneGentamycine
(3 days)
Cardiac SurgeryLead Removal
TOE Vegetations on
lead
Fever
Heart Rhythm 2006. May 17-20 Boston, USA
Heart Rhythm 2006. May 17-20 Boston, USA
TOE
• A multilobular vegetation attached
to the old abandoned lead near the
tricuspid valve
• Moderate tricuspid regurgitation
Heart Rhythm 2006. May 17-20 Boston, USA
Result
• Surgical removal under CPB
• Epicardial pacing with a VVIR pacing
system Lead Culture: S. Epidermidis
• Long term treatment with vancomycin
• Discharge after 4 weeks following surgery
• No recurrence of infection at 14 months
of follow-up.
Heart Rhythm 2006. May 17-20 Boston, USA
Heart Rhythm 2006. May 17-20 Boston, USA
Heart Rhythm 2006. May 17-20 Boston, USA
Heart Rhythm 2006. May 17-20 Boston, USA
Pacing System Complications
• Infection
• Lead malfunction
• Venous occlusion
Heart Rhythm 2006. May 17-20 Boston, USA
Pacing System Infection• Localized or superficial infection
−Localized pain, swelling−Purulent discharge
• Deep infection−Fever−Purulent discharge−Pulmonary thromboembolism−Recurrent pulmonary infection−Sepsis
Heart Rhythm 2006. May 17-20 Boston, USA
Pediatric Pacemaker Infections*•Perioperative Infections (before discharge):
−Superficial 1,2 %Superficial 1,2 %−Deep 0,2 %
•Early Pacemaker Early Pacemaker Infections (< 60 days)Infections (< 60 days)
−Superficial 3,1 %−Deep 1,2 %
•Late Pacemaker Infections
−Superficial 0,5 %−Deep 0,7 %
•Staphylococcus species were isolated in 44 %•Increased Risks
−ReinterventionReintervention−Down syndromeDown syndrome−Subcutaneous Subcutaneous preperitoneal pocketpreperitoneal pocket
* Cohen et al J Thorac Cardiovasc Surg 2002; 124.
Heart Rhythm 2006. May 17-20 Boston, USA
Pacing System Infection• Laboratory
−Complete blood count with differential analysis, eritrosit sedimentation rate
−CRP, circulating immun complexes−Blood and tissue culture−Gram staining−ECG and X-ray−Echocardiographic exam−Pulmonary perfusion sintigraphy
Heart Rhythm 2006. May 17-20 Boston, USA
Deep Infection
• Echo is very important for −to reveal intracardiac masses
• Vegetations• Strands• Abcess
−to determine the degree of tricuspid regurgitation
Heart Rhythm 2006. May 17-20 Boston, USA
Deep InfectionTransthoracic versus Transosephageal Echo
•TTE Limitations•Bad echo image (previous cardiac operations)•Lead related confusing echo signals•Inability to see strands
TOE
Pacemaker Lead Infectionn=23
Positive TTE7/23 (30 %)
Positive TOE21/23 (91 %)
Victor et al. Heart 1999; 81
Heart Rhythm 2006. May 17-20 Boston, USA
Treatment
• Localized Infection−Intravenous and oral antibiotics−Local debridman−Infrequently pacing system removal
• Fever and Positive Culture with
Negative TOE−Prolonged antibiotic usage
Heart Rhythm 2006. May 17-20 Boston, USA
Heart Rhythm 2006. May 17-20 Boston, USA
Deep Infection
• Pacing system removal mandatory−Interventional−Surgical−Hybrid procedures
• Antibiotics−>2 weeks intravenously− 6 weeks total
Heart Rhythm 2006. May 17-20 Boston, USA
Treatment Choices
•Surgery−Large vegetations (> 10mm)−Abcess formation−Broken lead−Abandoned old leads−Concomitant surgery need
•Intervention− Small vegetations− Strand formation− Lead amenable to extraction
Heart Rhythm 2006. May 17-20 Boston, USA
Interventional Treatment
• Simple traction
• Lead locking systems
• Laser or RF systems
• Femoral access
Heart Rhythm 2006. May 17-20 Boston, USA
Chest 2003; 12
Heart Rhythm 2006. May 17-20 Boston, USA
Europace 2006; 6
Heart Rhythm 2006. May 17-20 Boston, USA
Conclusions I
• Pacing system infection is not rare in children
• Deep infection involving the lead may present as purulent discharge and/or endocarditis or systemic infection
• TOE is the main diagnostic tool for the diagnosis of lead vegetations
Heart Rhythm 2006. May 17-20 Boston, USA
Conclusions II
• Pacing system removal is needed to cure the deep infection
• Removal may be done with lead extraction methods in the majority of patients
• Surgery is still mandatory in some patients
Heart Rhythm 2006. May 17-20 Boston, USA
PEDIRHYTHM III24-27TH OCTOBER
ISTANBUL, TURKEY