Assessing Risk of Bloodstream Infections in Patients With Cardiovascular Devices: From Endocarditis to Cardiovascular...

Infective endocarditis (IE) was historically the predominant cardiovascular infection, but its relative burden has declined. In contrast, infections related to prosthetic valves (PVE), transcatheter aortic valve implantation (TAVI), aortic vascular grafts and endografts (VGEs), cardiac implantable electronic devices (CIED), and ventricular assist devices (VADs) are increasing. This trend reflects an ageing population with complex devices, multiple comorbidities, and greater frailty, all of which contribute to higher susceptibility to device infection and bacteremia from other sources. In cardiovascular device carriers, bacteremia must be assessed for potential device infection. Key indicators include correlation within isolated microorganism and type of device, interval between device implantation and bacteremia, periprocedural complications in early infections, persistence of bacteremia, metastatic infection, absence of alternative focus, and time-to-positivity of blood cultures as a marker of bacterial load. Patient comorbidities, procedural complexity, and device-related factors further define risk. Risk scores validated for Gram-positive bacteremia assist in stratification and guide echocardiography, although none is specific for device carriers. Echocardiography remains central but has limited sensitivity in VGE, CIED, and VAD infections. Diagnostic accuracy increases substantially when combining echocardiography, positron emission tomography/computed tomography (PET/CT), and multidetector CT angiography; in PVE, sensitivity improves from 75% to 83% to nearly 100%; in CIED, increase from 34% to 56%; and in VAD, pooled sensitivity and specificity are 95% and 91%. In daily practice, bacteremia in a device carrier should always trigger systematic risk assessment, multimodal imaging, and multidisciplinary discussion within a Cardiovascular Infection Team, expanding the traditional Endocarditis Team to address the rising burden of cardiovascular device-related bloodstream infections.