Clinical manifestations of device-related infective endocarditis in cardiac resynchronization therapy recipients
Ewa Jędrzejczyk-Patej1, Michał Mazurek1, Oskar Kowalski1
1Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Centre for Heart Diseases, Zabrze, Poland.
Insights
Cardiac resynchronization therapy (CRT) recipients with device-related infective endocarditis (CDRIE) commonly present with fever. The modified Duke lead criteria (MDLC) demonstrate superior diagnostic accuracy for CDRIE compared to the modified Duke criteria (MDC).
Area of Science:
- Cardiology
- Infectious Diseases
- Medical Microbiology
Background:
- Cardiac device-related infective endocarditis (CDRIE) is a serious complication in patients with cardiac resynchronization therapy (CRT) devices.
- Understanding the microbiological characteristics and clinical manifestations of CDRIE is crucial for timely diagnosis and effective management.
- Existing diagnostic criteria, such as the modified Duke criteria (MDC), may have limitations in diagnosing CDRIE.
Purpose of the Study:
- To analyze the microbiological profiles and clinical presentations of CDRIE in CRT recipients.
- To compare the diagnostic performance of the modified Duke lead criteria (MDLC) against the modified Duke criteria (MDC) for CDRIE detection.
- To evaluate the inclusion of local infection and pulmonary embolism as major criteria within the MDLC.
Main Methods:
- A retrospective analysis of 765 consecutive CRT patients from a tertiary care center (2002-2015).
- Systematic screening for CDRIE in all included patients.
- Comparison of diagnostic accuracy between MDC and MDLC, with MDLC incorporating local infection and pulmonary infection/embolism.
Main Results:
- CDRIE developed in 5.36% of patients, often accompanied by pocket or pulmonary infections/embolism.
- Fever (95.1%) and positive blood cultures (65.9%) were common; *Staphylococcus* was the most frequent pathogen.
- MDLC identified definite CDRIE in 80.5% of cases, significantly higher than MDC's 48.8% (p=0.003).
Conclusions:
- Fever is the predominant symptom in CRT-related CDRIE, and transesophageal echocardiography is valuable for detecting vegetations.
- While *Staphylococci* are common, Gram-negative bacteria represent a significant proportion of CDRIE pathogens.
- The MDLC, by including local infection and pulmonary complications, offers superior diagnostic capability for CDRIE compared to MDC.
Introduction:
The aim of the study was to analyse microbiological characteristics and clinical manifestations of cardiac device-related infective endocarditis (CDRIE) in cardiac resynchronization therapy (CRT) recipients, and to compare the diagnostic value of modified Duke (MDC) versus modified Duke lead criteria (MDLC; including to MDC local infection and pulmonary infection or embolism as major criteria).
Material And Methods:
The study population comprised 765 consecutive CRT patients from a high-volume, tertiary care centre from 2002 to 2015. All patients were screened for CDRIE.
Results:
During a median follow-up of 1692 days (range: 457-3067) 5.36% of patients (n = 41) developed CDRIE, which was accompanied by CRT pocket infection in 17.1% (n = 7) and recurrent pulmonary infection or pulmonary embolism in 29.3% (n = 12). Fever was present in 95.1% of patients (n = 39), whereas blood cultures were positive in 65.9% (n = 27). Staphylococcus was the most prevalent pathogen in 59.3% (n = 16), Gram-negative bacteria in 25.9% (n = 7). Transoesophageal echocardiography showed intracardiac vegetations in 73.2% of patients (n = 30). Non-different pathogen types with the most common methicillin-sensitive Staphylococcus aureus were observed for early versus late CDRIE (endocarditis ≤ 6 vs. > 6 months from CRT or other device-related procedure). All 3 inflammatory markers (C-reactive protein, white blood cells, procalcitonin) were normal in 4.9% of patients (n = 2). MDC versus MDLC indicated definite CDRIE in 48.8% versus 80.5%, respectively (p = 0.003).
Conclusions:
Fever is the most common symptom of CRT-related CDRIE, and transoesophageal echocardiography allows vegetations to be visualised in nearly 3/4 of patients with CDRIE. Although the most common pathogens were Staphylococci, Gram-negative bacteria accounted for a quarter of CDRIE. Modified Duke lead criteria proved superior to MDC.
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