Top Things to Know: Update on Cardiovascular Implantable Electronic Device Infections and Their Prevention, Diagnosis and Management
Published: December 04, 2023
Prepared by Barbara Entl, MD
- Cardiovascular implantable electronic device infection (CIEDI) is a common complication of cardiovascular implantable electronic devices (CIED). This infection can be life-threatening and often challenging to diagnose, especially in a patient with complex medical conditions.
- This statement is a follow-up to the 2010 American Heart Association scientific statement "Update on Cardiovascular Implantable Electronic Device Infections and Their Management." It highlights significant advances in preventing, diagnosing, and managing these infections.
- In a patient receiving anticoagulant therapy and requiring CIED, continued or interrupted direct oral anticoagulants (DOACs) are both acceptable since both are associated with a low risk of hematoma formation following device placement.
- A significant challenge in establishing CIEDI diagnosis is the misclassification of lead echo-densities on echocardiography which can result in a false positive CIEDI diagnosis with subsequent removal of a non-infected device. Interpretation of transesophageal echocardiography findings within the clinical and microbiological context and never as a standalone test is advised.
- It is seemly to suspect CIED infection in any patient with CIED who presents with positive blood cultures for >72 hours (irrespective of the isolated microorganism), appropriate antimicrobial therapy, and no alternative differential diagnosis.
- In a febrile patient with other SIRS (systemic inflammatory response syndrome) criteria, negative blood cultures, and an unknown source of infection, 18F-FDG PET/CT uptake along leads or heart valves may help confirm the diagnosis of CIED lead infection.
- In a patient with lead or a low-grade pocket infection or who received antibiotic treatment prior to imaging, 18F-FDG PET/CT may have a reduced sensitivity and should be used with other diagnostic tests.
- The statement suggests that reimplantation of CIED be delayed until complete resolution of local and systemic infection and negative blood cultures for 72 hours. A 14-day delay between extraction of an infected device and device reimplantation is advised in a patient with valvular infective endocarditis.
- A patient at high risk of infection requiring single-chamber ventricular pacing may benefit from a leadless intracardiac pacemaker.
- Chronic antibiotic suppression after initial antibiotic therapy is warranted in select patients with CIEDI who are not eligible for complete device removal, such as the elderly, those with multiple comorbidities, or limited life expectancy.
Citation
Baddour LM, Esquer Garrigos Z, Sohail MR, Havers-Borgersen E, Krahn AD, Chu VH, Radke CS, Avari-Silva J, El-Chami MF, Miro JM, DeSimone DC; on behalf of the American Heart Association Council on Clinical Cardiology. Update on cardiovascular implantable electronic device infections and their prevention, diagnosis, and management: a scientific statement from the American Heart Association [published online ahead of print December 4, 2023]. Circulation. doi: 10.1161/CIR.0000000000001187