Pacemaker related endocarditis: analysis of seven cases

Vegetative electrode infection following permanent pacemaker implantation is a rare and serious complication. Among 1920 patients who underwent permanent pacemaker implantation in our institute between 1980 and 2000, 7 patients aged 65 to 78 years were diagnosed to have pacemaker related endocarditis. In this study, the clinical course and management strategies for these patients are reviewed. The most frequently encountered factors contributing to development of pacemaker infection were local complications such as postoperative hematoma and inflammation, and recurrent surgical interventions on the pacemaker system. In blood cultures S. aureus was the most common causative microorganism. Echocardiography could be performed in 5 patients. Three patients were referred to open-heart surgery for total removal of the pacemaker system, and one patient had his pacemaker system removed percutaneously. The remaining 3 patients did not agree to either surgical or percutaneous removal. These patients have been under antibiotic therapy for approximately 3 years and they still do not have any signs of a serious infection. Consequently, in patients with permanent pacemakers, infective endocarditis should be considered in the presence of fever and local symptoms. Blood cultures should be obtained and echocardiography should be performed. Complete removal of the pacemaker system with intensive antibiotic treatment is necessary for complete eradication of the infection. However, if percutaneous or surgical removal of the electrodes cannot be done because of high perioperative risk or the patient does not agree to undergo either method, medical treatment with long term antibiotic use may be considered as an alternative.     

Chronic bacterial endocarditis on the electrical catheter in a pacemaker wearer: a clinical case report]

This article reports a case of infective endocarditis in a patient with a permanent pacemaker 15 months after the generator had been replaced. The patient had Staphylococcus epidermidis isolated in several blood cultures. No interventional or clinical procedure with any risk of bacteremia was performed, nor was any infective complication of the pocket observed. Thus, the portal of entry of the etiologic agent is unclear. The role of transesophageal echocardiography in detecting pacemaker-induced endocarditis is very important and therapy of choice involves removal of the pacemaker system as soon as possible.     

Infective endocarditis following incomplete ablation of a pacemaker

Pacemaker lead-related infective endocarditis is uncommon but mortality remains high. We report the case of a 63-year-old man who presented with a history of intermittent low-grade fever and no other sign for 15 months. Fever had developed after incomplete removal of a pacemaker with the ventricular lead left in situ followed by a new implantation of cardiac stimulation material. Positive blood cultures and transesophageal echocardiography showing a vegetation on a pacemaker lead gave the diagnosis. Initial antibiotic therapy was insufficient and complete surgical extraction of the pacemaker and leads was required. A huge vegetation was seen on the old ventricular lead. The other leads were not affected. Outcome was good. The paucity of symptoms in pacemaker lead-related infective endocarditis makes diagnosis difficult. It must however be suspected in pacemaker patients with low-grade intermittent fever. Transesophageal echocardiography is required. Treatment must combine antibiotic therapy with material extraction.     

Pacemaker lead thrombo-endocarditis in an intravenous drug abuser

We report a 30-year-old male intravenous drug abuser presenting with persistent pacemaker lead thrombosis with superimposed pacemaker lead endocarditis. He underwent urgent surgery, but expired due to refractory sepsis. This case confirms that patients with pacemakers are at risk of developing pacemaker lead thrombosis. In addition, they are at high risk of developing pacemaker lead endocarditis if additional risk factors for endocarditis are present. We believe this case report is unusual on account of pacemaker lead thrombosis as well as endocarditis occurring in a patient with history of intravenous drug abuse. Whether pacemaker patients with multiple leads need to be on long-term antiplatelet or anticoagulation therapy necessitates further studies.     

Diagnosis and treatment of infective endocarditis. Current ESC guidelines

To account for the current evidence in the field of infective endocarditis and to harmonize deviant national guidelines, in 2009 the European Society of Cardiology published novel recommendations on the prevention, diagnosis and treatment of infective endocarditis.The most important changes can be found concerning antimicrobial prophylaxis for endocarditis, the antimicrobial treatment of endocarditis caused by S. aureus and the indications for surgical treatment.Due to the weak evidence about prophylactic administration of antibiotics before procedures at risk for bacteraemia to prevent infective endocarditis, the novel guidelines recommend prophylaxis only in patients with the highest risk for infection and lethal course of endocarditis. These are patients with prosthetic valves or prosthetic material used for cardiac repair, patients with previous endocarditis and patients with congenital heart disease. A narrow definition of procedures at risk was proposed only including dental procedures requiring manipulation of the gingival or periapical region of teeth.For endocarditis caused by S. aureus an additional gentamicin administration was previously recommended but this is now seen only as optional due to its nephrotoxicity. In methicillin-resistant strains daptomycin is a possible alternative to vancomycin. In strains susceptible to methicillin, beta-lactamic antibiotics were definitively preferred than the usage of vancomycin due to better outcome. The current guidelines recommend definitive timing and risk constellations for surgical treatment of infective endocarditis. For example, cardiac shock due to valvular lesions refractory to medical treatment should give rise to an emergency intervention within 24 h. Other indication groups contain uncontrolled infection and prevention of embolism and indications were defined as urgent or elective depending on the clinical situation.     

A critical appraisal of the quality of the management of infective endocarditis

OBJECTIVES: The purpose of this study was to assess the quality of the management of infective endocarditis. BACKGROUND: Although many guidelines on the management of infective endocarditis exist, the quality of this management has not been evaluated. METHODS: We collected data on all patients (116) hospitalized with infective endocarditis over 1 year in all hospitals in the Rh?ne-Alpes region (France). RESULTS: Prophylactic antibiotics were not given before infective endocarditis to 8/11 cardiac patients at risk and who underwent an at risk procedure. Among the 55 cardiac patients at risk and with fever and who consulted a physician, blood cultures were not performed before antibiotic therapy was initiated for 32 patients. In-hospital antibiotic therapy was incorrect for 23 patients. The portal of entry was not treated for 16/61 patients with an accessible portal of entry. Among the 19 patients who had severe heart failure or fever persisting more than 2 weeks in spite of antibiotic therapy and who could have undergone early surgery, surgery was delayed for five, and not performed for three. Overall, the average score was 15/20. CONCLUSIONS: More information on the management of infective endocarditis should be widely disseminated to the physicians' and the dentists' communities and to the patients at risk.     

Diagnostik und Therapie der Endokarditis

To account for the current evidence in the field of infective endocarditis and to harmonize deviant national guidelines, in 2009 the European Society of Cardiology published novel recommendations on the prevention, diagnosis and treatment of infective endocarditis. The most important changes can be found concerning antimicrobial prophylaxis for endocarditis, the antimicrobial treatment of endocarditis caused by S. aureus and the indications for surgical treatment. Due to the weak evidence about prophylactic administration of antibiotics before procedures at risk for bacteraemia to prevent infective endocarditis, the novel guidelines recommend prophylaxis only in patients with the highest risk for infection and lethal course of endocarditis. These are patients with prosthetic valves or prosthetic material used for cardiac repair, patients with previous endocarditis and patients with congenital heart disease. A narrow definition of procedures at risk was proposed only including dental procedures requiring manipulation of the gingival or periapical region of teeth. For endocarditis caused by S. aureus an additional gentamicin administration was previously recommended but this is now seen only as optional due to its nephrotoxicity. In methicillin-resistant strains daptomycin is a possible alternative to vancomycin. In strains susceptible to methicillin, beta-lactamic antibiotics were definitively preferred than the usage of vancomycin due to better outcome. The current guidelines recommend definitive timing and risk constellations for surgical treatment of infective endocarditis. For example, cardiac shock due to valvular lesions refractory to medical treatment should give rise to an emergency intervention within 24 h. Other indication groups contain uncontrolled infection and prevention of embolism and indications were defined as urgent or elective depending on the clinical situation.     

Infective endocarditis related to pacemaker leads. A review

Infective endocarditis is a rare but serious complication of permanent cardiac pacing with high mortality ranging from 10 to 30%. Clinical symptoms are sometimes acute but more often poor and aspecific in subacute and chronic forms causing prolonged diagnostic delay. In order to make endocarditis on pacemaker leads clearer, we conducted a medline search of all published literature. Analysis of this literature shows that the initial infective source is often local and that Staphylococcus species are the most often pathogens isolated. Clinicians have to search carefully for local inflammatory signs, past or ongoing, and pulmonary embolism because their presence will be helpful for diagnosis. Transoesophageal echocardiography is essential; it shows vegetations in more than 90% and must be repeated when the examination is negative. Treatment has a double goal: a prophylactic treatment in order to reduce risk factors of infection related to implantation of the pacemaker and a curative treatment associating prolonged antibiotic therapy with extraction of the material.     

心脏瓣膜术后Ⅲ度房室传导阻滞的临床分析

目的 探讨心脏瓣膜术后Ⅲ度房室传导阻滞（Ⅲ°AVB）的发生原因、影响因素及相关治疗措施.方法 回顾性分析我院2000年1月至2008年12月3674例心脏瓣膜术后9例发生持续性Ⅲ°AVB并行永久性起搏器置入术患者的临床资料.心脏病因：风湿性心脏瓣膜病2例,感染性心内膜炎2例,主动脉瓣二叶畸形2例（其中合并感染性心内膜炎1例）,退行性主动脉瓣病变1例,先天性房室管畸形1例（既往有心脏手术史）,二尖瓣脱垂及非对称性肥厚性心肌病各1例.行主动脉瓣置换4例、二尖瓣置换2例、二尖瓣置换及三尖瓣成形1例、Bentall术1例、左室流出道疏通及二尖瓣置换1例.结果 本组9例患者,术后早期出现Ⅲ°AVB 7例,术后24～48 h出现Ⅲ°AVB 1例,术后4年出现Ⅲ°AVB 1例.出现Ⅲ°AVB持续时间超过2～3周不能恢复者,均行永久性起搏器置入术,其中采用DDD起搏器4例、VVI起搏器5例.无晚期死亡患者.结论 心脏瓣膜术后出现Ⅲ°AVB大多发生于术后早期,与手术部位有一定关系.术中注重心脏瓣膜结构与房室结及传导束的解剖关系,是预防术后出现Ⅲ°AVB的关键.Ⅲ°AVB持续时间超过2～3周者需行永久性起搏器置入术.     

Procedures associated with infective endocarditis in adults: A case confrol study

OBJECT: To assess the relative risk of infective endocarditis associatedwith various procedures and the protective efficacy of antibioticprophylaxis by a case-control study. BACKGROUND: Recommendations for the prevention of infective endocarditisare based on the hypothesis of a relationship between proceduresand infective endocarditis which is supported by anecdotal reportsand data from experimental models. METHODS: Cases met the Von Reyn's diagnostic criteria modified with echocardiographicand macroscopic findings, Controls were recruited from cardiologyor medicinal wards. Cases (n=171) and controls were matchedas regards sex, age and underlying cardiac condition, They wererequested to indicate all the medical, surgical or dental procedureswithin the previous 3 months, Among potential confounding factors,infectious episodes and skin wounds in the previous 3 monthswere reported, Antibiotic prophylaxis administration was documentedfor type, dosage, duration and administration schedule. RESULTS: Cases significantly more frequently than controls had undergoneat least one procedure (matched odds ratio, 1.6; 95% confidenceinterval, 1.01 to 2.53). Dental procedures considered as a wholewere not associated with an increased risk, although scalingand root canal treatment showed a trend towards a higher riskof infective endocarditis (P=0.065). Among non-dental procedures,only surgery appeared to be at risk (matched odds ratio, 4.7;95% confidence interval, 1.02 to 22). Considering all procedures,the risk of infective endocarditis increased significantly withthe number of procedures. While general co-morbid conditionsdid not differ between the two groups, cases significantly morefrequently than controls had experienced an infectious episodeor a skin wound In multivariate analysis, only infectious episodesand skin wounds significantly increased the risk of infectiveendocarditis. Scaling was the only independent risk factor forviridans streptococcal infective endocarditis. The 46% protectiveefficacy of antibiotic prophylaxis was not significant. CONCLUSIONS: Procedures do increase the risk of infective endocarditis. Theinterpretation of the apparent low risk associated with dentalprocedures may be as a result of the current practice of antibioticprophylaxis. Our data suggest that surgery should be more clearlymentioned in future guidelines, and reemphasize that a rigoroustreatment of any focal infection in cardiac patients is mandatory.From the efficacy rate of antibiotic prophylaxis, it can beestimated that the overall incidence of infective endocarditismight be reduced by 5 to 10% in France by appropriate use ofantibiotic prophylaxis in cardiac patients.     

Surgical reconstruction of intervalvular fibrous body in active infective endocarditis

INTRODUCTION AND OBJECTIVES: Surgery for infective endocarditis with paravalvular abscesses and fibrous body destruction has the highest mortality and morbidity rates in this disease with high surgical risk. We report a new approach of radical resection of the abscess and affected tissues and reconstruction of the heart with pericardium as an alternative to conventional surgery. METHODS: In the last two years six patients with infective endocarditis, paravalvular abscesses and fibrous body destruction underwent surgery (five prostheses with infective endocarditis). The main indication for surgery was persistent sepsis despite adequate antibiotic treatment in five patients and congestive heart failure in one. After wide resection of the abscesses and fibrous body the heart was reconstructed with glutaraldehyde-fixed bovine pericardium. RESULTS: There was no hospital mortality. The median bypass and clamp times were 198 and 174 minutes, respectively. One patient presented complete AV block and a permanent transvenous pacemaker was implanted. Doppler echocardiographic studies performed in all the patients prior to discharge indicated that no patient had patch dehiscence or paravalvular leaks. Patients were followed a mean of 15 months with no deaths or other complications being reported. CONCLUSIONS: Resection of the abscesses and fibrous body, and reconstruction of the heart with glutaraldehyde-fixed bovine pericardial patch is a radical, feasible technique with all infected tissues being resected to thereby prevent reinfection or paravalvular leaks.     

Procedures associated with infective endocarditis in adults: A case confrol study

OBJECT:: To assess the relative risk of infective endocarditis associatedwith various procedures and the protective efficacy of antibioticprophylaxis by a case-control study. BACKGROUND:: Recommendations for the prevention of infective endocarditisare based on the hypothesis of a relationship between proceduresand infective endocarditis which is supported by anecdotal reportsand data from experimental models. METHODS:: Cases met the Von Reyn's diagnostic criteria modified with echocardiographicand macroscopic findings, Controls were recruited from cardiologyor medicinal wards. Cases (n=171) and controls were matchedas regards sex, age and underlying cardiac condition, They wererequested to indicate all the medical, surgical or dental procedureswithin the previous 3 months, Among potential confounding factors,infectious episodes and skin wounds in the previous 3 monthswere reported, Antibiotic prophylaxis administration was documentedfor type, dosage, duration and administration schedule. RESULTS:: Cases significantly more frequently than controls had undergoneat least one procedure (matched odds ratio, 1·6; 95%confidence interval, 1·01 to 2·53). Dental proceduresconsidered as a whole were not associated with an increasedrisk, although scaling and root canal treatment showed a trendtowards a higher risk of infective endocarditis (P=0·065).Among non-dental procedures, only surgery appeared to be atrisk (matched odds ratio, 4·7; 95% confidence interval,1·02 to 22). Considering all procedures, the risk ofinfective endocarditis increased significantly with the numberof procedures. While general co-morbid conditions did not differbetween the two groups, cases significantly more frequentlythan controls had experienced an infectious episode or a skinwound In multivariate analysis, only infectious episodes andskin wounds significantly increased the risk of infective endocarditis.Scaling was the only independent risk factor for viridans streptococcalinfective endocarditis. The 46% protective efficacy of antibioticprophylaxis was not significant. CONCLUSIONS:: Procedures do increase the risk of infective endocarditis. Theinterpretation of the apparent low risk associated with dentalprocedures may be as a result of the current practice of antibioticprophylaxis. Our data suggest that surgery should be more clearlymentioned in future guidelines, and reemphasize that a rigoroustreatment of any focal infection in cardiac patients is mandatory.From the efficacy rate of antibiotic prophylaxis, it can beestimated that the overall incidence of infective endocarditismight be reduced by 5 to 10% in France by appropriate use ofantibiotic prophylaxis in cardiac patients.     

Piercing and tattoos in patients with congenital heart disease -- is it a problem?

Piercing and tattooing enjoy widespread popularity in modern society. Patients with congenital heart disease are at elevated risk for infective endocarditis. However, it is not yet known whether piercing and tattooing are dangerous for these patients.A search of the literature provided 10 published cases of infective endocarditis after piercing or tattooing. Affected patients were adolescents or young adults ranging in age from 13 to 30 years (5 male, 5 female). Four of the patients had a known cardiac risk factor for endocarditis (bicuspid aortic valve, postoperative trans-position of the great arteries, postoperative coarctation, postoperative aortic valve stenosis). Piercing preceded endocarditis in 9 cases (4 times mouth, 2 ear, 1 nose, 1 breast, 1 navel), one tattoo. The following agents were isolated: S. aureus in 4 cases, 2 S. epidermidis, 1 Str. viridans, 1 Neisseria mucosa, 1 Haemophilus aphrophilus, 1 Haemophilus parainfluenzae. All patients were treated with antibiotics. Six patients underwent cardiac surgery (5 of them valve replacement). Patients with congenital heart disease constitute less than 1% of the population. Thus, they are clearly overrepresented in the published literature. Epidemiologic conclusions are not possible from these data. However, patients with congenital heart disease and their parents should be strongly advised against piercing and tattooing with regard to the risk of infective endocarditis.     

起搏器心内膜炎的外科治疗

目的　介绍 15例起搏器心内膜炎外科治疗的临床经验 ,讨论手术指征和时机。方法　1993年至 2 0 0 1年间 ,我们为 15例起搏器心内膜炎患者 ,施行了体外循环直视下心内起搏电极撤除术。本文对这些病人的临床资料进行回顾性研究。结果　本组病例中 ,有 2例院内死亡 ,术后随访期内 (中间值 =31 3个月 ;区间 ,1 8～ 5 8 7个月 )无远期死亡 ,总死亡率为 13 3%。所有出院病人均无感染复发。大部分病人心功能明显改善 (P <0 0 1)。只有 6例患者术后因持续存在的心律失常需要重新安装起搏器。本组病例中常见的外科手术指征为 :1)附着于起搏电极的大型赘生物 ,2 )顽固感染 ,3)三尖瓣架构损坏 ,4)肺栓塞 ,5 )存在需要外科处理的基础的或并存的心脏病变。结论　根据我们的结果及相关文献报道 ,我们认为对患起搏器心内膜炎的病人 ,应尽早采用外科手术撤除植入的心内起搏器硬件。手术治疗的远期效果是值得信赖的。     

Aspergillus fumigatus pacemaker lead endocarditis: a case report and review of the literature

The diagnosis of fungal endocarditis requires a high index of clinical suspicion. Rarely, pacemaker implantation may be a risk factor for the development of fungal endocarditis. A 71-year-old man with a history of multiple transvenous pacemaker manipulations and fever of an uncertain source is described. A diagnosis of culture-negative pacemaker endocarditis was established only after repeat transthoracic echocardiography. Amphotericin B was instituted; however, the patient developed a cerebral infarct and died. Postmortem examination demonstrated Aspergillus fumigatus within a large pacemaker lead thrombus, tricuspid and aortic valve vegetations, and septic pulmonary and renal emboli. The present report describes the clinical and pathological features of a rare case of Aspergillus fumigatus pacemaker lead endocarditis and suggests that serial echocardiograms may be effective in the early detection of pacemaker lead vegetations. The diagnostic features and therapeutic management of pacemaker lead endocarditis are reviewed.     

Transesophageal echocardiography (TEE) in the evaluation of infective endocarditis

Echocardiography is an essential tool for the modern diagnosis and management of infective endocarditis and its complications. The negative predictive value of surface imaging is inadequate to rule out endocarditis in most instances; diagnostic sensitivity is improved by way of the transesophageal approach. The clinical scenario and pretest probability of disease should guide the use of transesophageal versus transthoracic imaging. Those at high risk for endocarditis or its complications in particular should undergo early TEE. Serial studies may be required to guide management. In the setting of an initially negative echocardiographic study, a repeat examination is indicated if the clinical suspicion of endocarditis persists or if the clinical picture changes. Combined transthoracic echocardiography and TEE may supply complementary information useful in management and follow-up. As most published research predates recent advances in imaging, the impact of changing technology, such as harmonic and three-dimensional imaging, in the management of endocarditis is yet to be determined.     

Immunization for prevention of infective endocarditis

Immunization has been used for many years to prevent certain infectious diseases. Often it is targeted to populations at increased risk of a particular infection. Patients at increased risk of infective endocarditis can be identified and would be eligible candidates for immunization if vaccines were available to prevent common bacterial causes of infective endocarditis. The idea of using preventive therapy among patients at increased risk of infective endocarditis is not novel, and recommendations for use of antibiotics prior to performing certain invasive procedures have been in place for years. Findings from immunization experiments using animal models of experimental endocarditis support the notion that vaccine development is appropriate for study in humans, and these findings are reviewed in this paper.     

Immunization for prevention of infective endocarditis

Immunization has been used for many years to prevent certain infectious diseases. Often it is targeted to populations at increased risk of a particular infection. Patients at increased risk of infective endocarditis can be identified and would be eligible candidates for immunization if vaccines were available to prevent common bacterial causes of infective endocarditis. The idea of using preventive therapy among patients at increased risk of infective endocarditis is not novel, and recommendations for use of antibiotics prior to performing certain invasive procedures have been in place for years. Findings from immunization experiments using animal models of experimental endocarditis support the notion that vaccine development is appropriate for study in humans, and these findings are reviewed in this paper.     

Manifestaciones osteoarticulares de endocarditis

Infective endocarditis is a fatal disease unless specifically treated. This entity must be suspected immediately in all patients with fever or sepsis and heart murmur and an echocardiogram should be performed to confirm the diagnosis.In a few case series, a significant proportion of patients diagnosed with infective endocarditis showed osteoarticular involvement, which preceded, sometimes by months, the onset of specific symptoms of endocarditis.Even when no specific musculoskeletal symptoms associated with endocarditis are found, these symptoms must be kept in mind and infective endocarditis should be suspected when musculoskeletal manifestations are the presenting symptom, because of the potentially dire consequences of delaying specific antibiotic treatment.     

Pacemaker endocarditis during 18 years in Göteborg

Pacemaker endocarditis is a rare but serious complication. Few studies addressing its treatment have been published. Clinical characteristics and outcome were retrospectively studied in 38 patients with 44 episodes of pacemaker infective endocarditis (PMIE) in G?teborg, during 1984-2001. The male/female ratio of episodes was 27/17 and the mean age 69 y. Transthoracic echocardiography (TTE) showed vegetation in 4/22 (18%) episodes and transoesophageal echocardiography (TEE) in 22/33 (67%). Staphylococci were isolated in 66% of blood cultures. The pacemaker system (PS) was removed in 28 episodes and in 18 of these there were no signs of reinfection at follow-up. In 16 episodes the PS was not removed, and in 13 of these, signs of infection were found at follow-up. Thus, the present study of PMIE showed staphylococci to be predominant causative agents and demonstrated a high diagnostic sensitivity of TEE. According to our results, PM removal rather than conservative treatment should be considered in all cases.