Nonvalvular cardiovascular device-related infections

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

All implanted cardiac devices can become infected which generally requires removal of the entire device (including pacing leads).

A biofilm forms on the surface of the device and this surface facilitates the attachment of the infectious agent. Antibiotics are ineffective in treating the infection of a biofilm as there is no blood flow into the biofilm.

• Coagulase negative staphylococci: 42%
• Methicillin sensitive staph aureus: 25%
• Gram negative bacilli: 9%
• Culture negative: 7%
• Polymicrobial: 7%
• Other gm + cocci: 4%
• Methicillin resistant staph aureus: 4%
• Fungal: 2%

There is a rise in the number of cases of CIED infections due to a larger number of devices being implanted, the frequency with which they are being replaced, and the comorbidities of patients in whom the devices are implanted.

• Pacemaker: 0.13% to 19.9%
• Defibrillator: 0% to 3.2%
• LVAD: 25% to 70%
• Ventriculoatrial shunt: 2.4% to 9.4%
• Vascular grafts: 1% to 6%
• Intra-aortic balloon pumps: 5% to 26%
• Arterial closure device: 1.9%
• Vena cava filter: rare
• Coronary artery stents: rare
• Peripheral stent: rare
• PDA, ASD, VSD occlusion device: rare

• Revision of a pocket is associated with a 4 to 6 times higher rate of infection.
• Automatic implantable cardiac defibrillators (AICDs) are associated with a higher rate of infection than permanent pacemakers: 8.9/1,000 device years versus 1.0/1,000 device years (p<0.001)
• Hematoma formation
• Warfarin use
• Re-intervention at the pocket site
• Renal failure
• Lack of primary prophylaxis during the initial insertion of the device

Complications of the device extraction that is necessary in CIED infection include:

• Bleeding
• Tricuspid valve trauma
• Pulmonary embolism
• Myocardial infarction
• Death

Risk factors for complications with device extraction include older age and co-morbidities.

TEE sensitivity is 95% TTE sensitivity is <30%

• Complete device extraction including the leads is required.
• The biofilm cannot be treated with antibiotics.
• Antibiotics directed at the pathogen should be administered, but there is no data to guide the route and the duration of treatment.
• There is no data to guide decisions regarding the implantation of a new device.

• Perioperative antibiotic therapy during the initial insertion of the device has been associated with prevention of CIED infection (trial stopped prematurely due to a RR of 0.19, p=0.016).