Prevalence and Outcome of Bacterial Endocarditis in Patients with Implantable Cardiac Devices Infections
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Prevalence and Outcome of Bacterial Endocarditis in Patients with Implantable Cardiac Devices Infections,ASHRAF W. ANDRAOS, KHALED H. HUSSEIN, SHERIF H. ZAKY, GAMAL HAMED, SALAMA H. OMAR, RANDA ALY, DALIA RAGAB, ABDO ELAZAB, OSAMA TAYEA, SAYED AKL and HASAN K.H. NAGY
Abstract
Background: cardiac device infection (CDI) is a devas-tating complication of permanent pacemakers (PPM) or im-plantable cardioverter-defibrillators (ICD). The incidence and outcome of endocarditis among patients (Pts) with CDI is not well defined.
The Aim of this Study: Is to report the experience in the prevalence, clinical presentations and management of bacterial endocarditis (BE) among patients with CDI in a tertiary care cardiac center over 25 years.
Methods: A total of 2630 cardiac devices implanted in a cohort of 2367 patients (pts) over 25 years were studied. Out of these, 117 (4.4%) Pts presented with CDI. Clinical, bacte-riologic and both transthoracic (TTE) and transoesophageal Echocardiographic (TEE) assessments were done.
Results: Of the 117 Pts with CDI (90 males, age ranging 18-82 yrs, mean=63±6 ys), 87 (74%) had redo procedures (battery replacement in 50, repositioning of leads in 12, device extrusion in 15 or evacuation of significant haematoma in 10 pts). Of these 87 pts, 65 had re-implants on the same day of explantation. In 30 pts (26%) no apparent cause of PI was identified. Out of the 117 Pts with CDI, 30 pts (26% of CDI and 1.1% of total procedures) had device-related BE with vegetations appeared in all pts by TEE (15 DDD, 9 VVI, 3 CRT & 3 ICD). The clinical presentations were prolonged fever in 25 pts (83%), significant pulmonary hypertension with thrombo-embolism in 3 pts (10%), severe sepsis and multi-organ failure in 2 pts (6%). Twenty-eight pts (93%) had positive blood cultures [staph.aureus in 23 (77%) and entero-cocci in 5]. There were only 2 pt with negative blood cultures. Device lead vegetations were evident in 20 pts (>10mm diameter in 13 pts). Ten pts presented with only right heart valves vegetations. Out of the 30 BE pts, 28 (93%) had PI while 2 pts had no apparent cause but frequent intravenous injections (one drug addict and one on regular haemodialysis). Out of the 20 pts with lead endocarditis 15 had their leads removed surgically with re-implantation of either epicardial (6 pts) or endocardial leads (9 pts). Fifteen pts had only medical treatment with proper antibiotics (5 pts with lead BE and all 10 pts with valvular BE). Four pts (13%) died; all had their devices implanted on same day of explanation.
Conclusion: Cardiac devices Redo procedures are major risk factors for CDI specially re-implantation on same day. Device related BE carries a serious morbidity and mortality, yet surgical removal of the whole system is the management of choice. Blood stream bactraemia is a potential risk factor in patients with cardiac devices and warrant prophylaxis against BE.