Outcome and microbiological findings of patients with cardiac implantable electronic device infection.

INTRODUCTION: Infections associated with cardiac implantable electronic devices (CIEDs) are a multifactorial disease that leads to increased morbidity and mortality. OBJECTIVE: The aim was to analyze patient-, disease- and treatment-related characteristics including microbiological and bacterial spectrum according to survival status and to identify risk factors for 1- and 3-year mortality in patients with local and systemic CIED infection. METHODS: In a retrospective cohort study, we analyzed data from patients with CIED-related local or systemic infection undergoing successful transvenous lead extraction (TLE). Survival status as well as incidence and cause of rehospitalization were recorded. Microbiology and antibiotics used as first-line therapy were compared according to mortality. Independent risk factors for 1- and 3-year mortality were determined. RESULTS: Data from 243 Patients were analyzed. In-hospital mortality was 2.5%. Mortality rates at 30 days, 1- and 3 years were 4.1%, 18.1% and 30%, respectively. Seventy-four (30.5%) patients had systemic bacterial infection. Independent risk factors for 1-year mortality included age (OR 1.05 [1.01-1.10], p = 0.014), NT-proBNP at admission (OR 4.18 [1.81-9.65], p = 0.001), new onset or worsened tricuspid regurgitation after TLE (OR 6.04 [1.58-23.02], p = 0.009), and systemic infection (OR 2.76 [1.08-7.03], p = 0.034), whereas systemic infection was no longer an independent risk factor for 3-year mortality. Staphylococcus aureus was found in 18.1% of patients who survived and in 25% of those who died, p = 0.092. There was a high proportion of methicillin-resistant strains among coagulase-negative staphylococci (16.5%) compared to Staphylococcus aureus (1.2%). CONCLUSIONS: Staphylococci are the most common causative germs of CIED-infection with coagulase-negative staphylococci showing higher resistance rates to antibiotics. The independent risk factors for increased long-term mortality could contribute to individual risk stratification and well-founded treatment decisions in clinical routine. Especially the role of tricuspid regurgitation as a complication after TLE should be investigated in future studies.

Predictors of permanent pacemaker implantation after transcatheter aortic valve implantation for aortic stenosis using Medtronic new generation self-expanding CoreValve Evolut R.

Conduction disturbance requiring permanent pacemaker (PPM) implantation is a common complication after transcatheter aortic valve implantation (TAVI) using Medtronic self-expanding CoreValve, and has remained common following the introduction of the new generation CoreValve Evolut R device. The aim of this study was to identify the determinants of PPM implantation after TAVI with CoreValve Evolut R. We retrospectively examined 114 patients who underwent transfemoral TAVI using CoreValve Evolut R. We excluded 17 patients with preprocedural PPM, 1 patient requiring Edwards SAPIEN 3 implantation after CoreValve Evolut R implantation, and 4 patients who died during the hospital admission. Thus, 92 patients were finally included in the analysis. Seventeen patients (18%) underwent new PPM implantation after TAVI. Preprocedural electrocardiography showed a lower ventricular rate and more right bundle branch block (RBBB) in patients with new PPM implantation compared to those without. Quantitative multidetector computed tomography assessment revealed larger aortic valve calcification (AVC) and higher asymmetry (∆AVC) in patients with new PPM implantation compared to those without. The univariate logistic regression analysis demonstrated that preprocedural ventricular rate ≤ 70 beats per minute, RBBB, AVC ≥ 110 mm3, and ∆AVC ≥ 45 mm3 were associated with new PPM implantation. Number of these factors clearly stratified the risk of new PPM implantation. In conclusion, PPM implantation occurs in 18% of patients undergoing TAVI with the new generation CoreValve Evolut R. Lower preprocedural ventricular rate, RBBB, larger AVC, and higher ∆AVC are associated with new PPM implantation after TAVI using the new generation CoreValve Evolut R.

Laparoscopic repositioning of a dislocated pacemaker into the rectovesical pouch.

Dislocation of the epicardial pacemaker into the peritoneal cavity is an uncommon but potentially life-threatening complication. We report a case of a 74 year old with an abdominally implanted epicardial pacemaker that migrated through the peritoneum to the excavatio rectovesicalis. The laparoscopic approach was chosen because of the increased risks of perioperative morbidity and decreased survival. The generator was implanted into a pocket beneath the anterior rectus sheath and the lead was peritonalized with a running suture. In conclusion, a laparoscopic retrieval is feasible and safe in the treatment of a displaced pacemaker in the rectovesical pouch.

Prognosis associated with redo cardiac resynchronization therapy following complete device and lead extraction due to device-related infection.

Aims: An increase in the number of cardiac resynchronization therapy (CRT) device implantations worldwide has led to a consequent increase in the number of infections associated with the device, making extraction of the CRT device inevitable. Redo CRT implantation after treatment and recovery following device extraction is challenging. This study aimed to evaluate the success rate, complications, and long-term prognosis of redo CRT implantation, including the rates of subclavian, cava, and coronary sinus (CS) vein thrombosis as well as re-infection. Methods and results: Between 2007 and 2014, 1712 lead extractions were performed in 537 patients with device-related infection at Heart Center Brandenburg. Of the 537 patients, 125 (23%) underwent CRT device and lead extraction, including extraction of the left ventricular lead from the coronary sinus. Of these 125, 62 (50%) patients underwent redo CRT implantation (mean age, 68 ± 10 years); 34 patients had coronary artery disease (CAD) while 28 had dilated cardiomyopathy (DCM). The mean left ventricular ejection fraction was 27% ± 7%. The mean QRS duration of the left bundle branch block was 158 (range, 147-162) ms, and 25 patients had atrial fibrillation (AF). All these patients were followed up for a median duration of 29.6 (range, 15-43) months. In 53 of the 62 patients (85%), the CRT system was successfully re-implanted; however, the original CS vein could be used again only in 28 (45%) patients. The all-cause mortality rate was 7.1% after 1 year, and it was significantly higher in patients whose N-terminal pro B-type natriuretic peptide level was ≥3,000 pg/mL (P < 0.001), those who were aged ≥64 years (P = 0.028), those who had CAD (P = 0.042) or chronic kidney insufficiency (P = 0.001), those with AF (P = 0.001) and those whose blood cultures were positive for Staphylococcus aureus (P = 0.014). Conclusion: Redo CRT implantation after device extraction owing to device-related infection has a low success rate and shows a higher rate of re-infection than that observed in patients who undergo CRT implantation for the first time. Further, patients whose blood cultures are positive for S. aureus show a particularly poor outcome.

Influence of pacing configurations, body mass index, and position of coronary sinus lead on frequency of phrenic nerve stimulation and pacing thresholds under cardiac resynchronization therapy.

AIMS: Phrenic nerve stimulation (PNS) can affect, and in some cases considerably limit, the long-term success of cardiac resynchronization therapy (CRT) therapy. To address this common problem, the manufacturers of CRT devices offer a range of configurations aimed at preventing high left ventricular pacing thresholds (LVPTs) and PNS. METHODS AND RESULTS: In 101 consecutive patients who had undergone implantation of a CRT system, we investigated prospectively the parameters LVPT and PNS threshold in relation to coronary sinus (CS) lead position, CS lead configuration, body position, and body mass index. With the configurations LV tip to right ventricular (RV) coil, LV tip to LV ring, and LV ring to RV coil, the LVPT and PNS threshold of patients with LV pacing were measured in the supine and left lateral body positions. The overall mean LVPT was lowest in LV tip to RV coil and highest in LV ring to RV coil configurations. The lowest PNS thresholds were measured in LV tip to RV coil and the highest in LV tip to ring configurations. The LVPT was not affected by body position and was stable in the standard supine and left lateral positions. CONCLUSION: Flexible LV pacing configurations are a useful feature of CRT systems for preventing PNS. The optimal LV pacing configuration should be determined on the basis of individual patient testing.