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Pacemaker infective endocarditis
P Cacoub1, P Leprince, P Nataf
1Department of Internal Medicine, Hôpital La Pitié-Salpétrière, Paris, France.
Insights
Pacemaker endocarditis, an infection of cardiac device leads, primarily affects older adults and is often caused by Staphylococcus species. Early diagnosis and treatment, including lead removal and antibiotics, are crucial for patient outcomes.
Area of Science:
- Cardiology
- Infectious Diseases
- Medical Device Infections
Background:
- Pacemaker endocarditis is a serious complication of cardiac electronic device implantation.
- Identifying risk factors and diagnostic challenges is crucial for managing this condition.
Purpose of the Study:
- To investigate the clinical characteristics, diagnostic methods, causative pathogens, and outcomes of pacemaker endocarditis.
- To evaluate the effectiveness of current treatment strategies.
Main Methods:
- Retrospective analysis of 33 patients with confirmed pacemaker endocarditis.
- Review of clinical data, diagnostic imaging (echocardiography, scintigraphy), microbiological cultures, and treatment outcomes.
- Comparison of diagnostic accuracy between transthoracic and transesophageal echocardiography.
Main Results:
- The majority of patients were over 60 years old, with Staphylococcus epidermidis and Staphylococcus aureus being the most common pathogens.
- Transesophageal echocardiography demonstrated significantly higher sensitivity (96%) in detecting vegetations compared to transthoracic echocardiography (2/9 patients).
- Overall mortality was 24%, with older patients experiencing higher mortality rates.
Conclusions:
- Pacemaker endocarditis requires prompt diagnosis and aggressive management, including device lead extraction and prolonged antibiotic therapy.
- Transesophageal echocardiography is superior to transthoracic echocardiography for diagnosing pacemaker endocarditis.
- Age is a significant factor influencing mortality in patients with pacemaker endocarditis.
Abstract:
We identified 33 patients with definite pacemaker endocarditis--that is, with direct evidence of infective endocarditis, based on surgery or autopsy histologic findings of or bacteriologic findings (Gram stain or culture) of valvular vegetation or electrode-tip wire vegetation. Most of the patients (75%) were > or = 60 years of age (mean 66 +/- 3; range 21 to 86). Pouch hematoma or inflammation was common (58%), but other predisposing factors for endocarditis were rare. At the time that pacemaker endocarditis was found, the mean number of leads was 2.4 +/- 1.1 (range 1 to 7). The interval from the last procedure to diagnosis of endocarditis was 20 +/- 4 months (range 1 to 72). Endocarditis appeared after pacemaker implantation, early (< 3 months) in 10 patients and late (> or = 3 months) in 23 patients. Fever was the most common symptom, being isolated in 36%, associated with a poor general condition in 24%, and associated with septic shock in 9%. Transthoracic echocardiography showed vegetations in only 2 of 9 patients. Transesophageal echocardiography demonstrated the presence of lead vegetations (n = 20) or tricuspid vegetations (n = 3) in 23 of 24 patients (96%; p <0.0001 compared with transthoracic echocardiography). Pulmonary scintigraphy showed a typical pulmonary embolization in 7 of 17 patients (41%). Pathogens were mainly isolated from blood (82%) and lead (91%) cultures. The major pathogens causing pacemaker endocarditis were Staphylococcus epidermidis (n = 17) and S. aureus (n = 7). S. epidermidis was found more often in early than in late endocarditis (90% vs 50%; p = 0.05). All patients were treated with prolonged antibiotic regimens before and after electrode removal. Electrode removal was achieved by surgery (n = 29) or traction (n = 4). Associated procedures were performed in 9 patients. After the intensive care period, only 17 patients needed a new permanent pacemaker. Overall mortality was 24% after a mean follow-up period of 22 +/- 4 months (range 1 to 88). Eight patients who were significantly older (74 +/- 3 vs 63 +/- 3 years; p = 0.05) died < or = 2 months after electrode removal, whereas 25 were alive and asymptomatic.