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

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