RESUMO
Cardiac implantable electronic devices are now widely used worldwide and the numbers are increasing exponentially. Subsequently, long-term complications have increased. Transvenous lead-extraction (TLE) is the gold standard for removing infected devices, treating systemic device-related infections including endocarditis, and removing devices for other non-infectious complications. Most patients still require device therapy after TLE for several indications, including lifesaving defibrillation or pacing in pacemaker-dependent patients. The decision to reimplant is challenging, particularly when the primary cause for device removal includes device-related infections and patients frequently are pacemaker dependent. We aim to present our strategy for reimplanting after performing TLE in 88 consecutive patients. We performed transvenous removal of 150 pacemaker and defibrillator leads, of which 74% for local or systemic infection. We report a 99.3% clinical success after TLE. Out of 88 patients who had undergone TLE and after reanalysing the device indication, 67 patients (76%) still had indication for device removal, but three of them refused to undergo reimplant and 58 were re-implanted. Of the re-implanted patients, 58.6% were implanted on the contra-lateral side, 38% on the ipsilateral side and two patients who had been previously implanted with ICD were reimplanted with a subcutaneous implantable cardioverter defibrillator (S-ICD). Up to 34.4% of patients were re-implanted during the same TLE procedure, which was performed for device up-grade in patients with venous occlusion, 24% were implanted during the same hospital admission for TLE but not during TLE, and 41.3% were discharged and reimplanted afterwards. With this strategy for reimplantation, we report no re-infections and no device-removal-related arrhythmic major events or deaths during one-year follow-up. In conclusion, most patients still require device therapy after TLE. In patients with previous infection of the device, the reimplantation strategy should be carefully analyzed to prevent infection relapse and limit the consequences of the absence of the device.
RESUMO
Infective endocarditis (IE) is a disease of the endocardium, which leads to the appearance of vegetation on the valves, cardiac structures, or, potentially, vascular endothelium of the heart. The risk of IE can be increased more than 140 times by congenital heart disease (50-59% of all IE), particularly if cyanotic. An increase in mortality may result from IE in patients with a complex cardiac pathology or patients with an implanted prosthetic material, most frequently conduits in a pulmonary position. Cardiac implantable electronic devices (CIED) infective endocarditis is a life-threatening complication representing 10% of all cases of endocarditis. Common signs of presentation are often fever and chills; redness and swelling at the pocket of the pacemaker, including the erosion and exteriorization of the device; and life-threatening sepsis. The use of intracardiac echocardiography for the diagnosis of IE is an innovative method. This may be needed, especially in older children undergoing complex cardiac surgery, when transthoracic echocardiography (TTE) and transesophageal echocardiography (TOE) failed to provide a reliable diagnosis. The 2018 European Heart Rhythm Association (EHRA) experts' consensus statement on transvenous lead extraction recommends complete device removal and antimicrobial therapy for any device-related infection, including CIED-IE. The most detected microorganism was Staphylococcus Aureus. In addition, cardiac surgery and interventional cardiology associated with the placement of prostheses or conduits may increase the risk of IE up to 1.6% for Melody valve implantation. Our manuscript presents a comprehensive review of infective endocarditis associated with cardiac devices and prostheses in the pediatric population, including recent advances in diagnosis and management.
