EP Lab Digest - September 2007 - (Page 20)

20 EP DEVICES SEPTEMBER 2007 Electrophysiologic Management and Treatment of Chronic and Acute Cardiac Device Infection Michelle D. Meyer, RN, BSN and James D. Maloney, MD St. Joseph Medical Center Carondelet Heart Institute Kansas City, Missouri ver the last 20 years, the transvenous techniques for the extraction of chronically implanted cardiac device leads have achieved a high success rate. However, the procedures are often intricate and are associated with a small but significant risk. The physician’s experience and the availability of different approaches for challenging cases can affect both the results and any associated complications. O Potentially lethal complications include arterial-venous fistula and/or dissecting hematoma, tears into the thoracic cavity, and tears of the superior vena cava (SVC) and/or heart wall.These potentially lethal complications all result from vascular tissue disruption during lead extraction. Disruptions are caused by tears, cutting, perforations, or separation of a vascular wall. Tearing or cutting of the SVC or atrial wall has been found to be the most common complication resulting in cardiac tamponade. Indications are difficult to describe because of the complexities associated with device-related complications and procedure-related risk.Various reasons for lead extraction can be due to a patient’s device-related infection, formation of a channel, or superfluous leads. In order to proceed with an extraction, physicians should estimate if the risks of not proceeding with the extraction would be greater than the potential risks of the lead extraction itself. Specifically, the presence of infection in a lead mandates extraction, while the creation of a conduit or channel is a necessary (though not mandatory) indication. Importantly, superfluous leads are noted only as a discretionary indication. Research on lead extraction can be found in literature. For example, Ellenbogen et al write that “the risk of S. aureus device infection without extraction was supported by a series of 33 patients from Duke Medical Center, in which 10 (47.6%) of 21 patients died without lead extraction, and 2 (16.7%) of 12 died despite lead Antibiotics are essential to the management of device infections. They should be used in conjunction with the corrective surgical procedures. extraction, and none from lead extraction.The safety and efficacy of complete lead extraction, with debridement and delayed re-implantation at a remote anatomic site, were demonstrated in 123 patients at the Cleveland Clinic Foundation with device infection. Despite infections from a wide range of bacterial organisms (mostly coagulatenegative staphylococci and S. aureus), extraction was associated with no major complications. Infection reoccurred only in those four patients who had incomplete extraction or re-implantation concurrent with the extraction.”1 Staphylococci are the cause of 88% of all device-related infections. 1 Staphylococci are defined as “gram-positive bacteria, pyrogenic (pus producing), slime producers, and clinically separated into coagulate-positive and coagulatenegative types.”1 Although some of these bacteria are capable of producing exotoxins (powerful soluble toxin produced by a bacterium), neurotoxins and endotoxins (toxin produced within a certain bacteria that is released only when the bacteria disintegrate), they usually are not associated with device infections. In addition, when categorizing staphylococci, it is important to note whether or not there is slime production, because “the pathogenic organisms may be the slime producers. Slime production definitely enhances their effectiveness as a pathogen in device infections.The ability to adhere to smooth surfaces, such as an implanted device and encapsulating fibrous tissue, is a major factor enhancing the infectivity of these bacteria.”1 Slime helps protect the bacteria from the body’s defense mechanisms and from antibiotics. It is important to also mention that “staphylococci are naturally separated in the identification phase into the pathogenic coagulate-positive species (S. aureus) and the relatively nonpathogenic coagulatenegative species (S. epidermidis).” 1 Septicemia is caused by drainage of bacteria and/or their toxins into the bloodstream through the vein entry site along the lead, through breaks in the lead insulation, through a venous branch draining in the pocket, or, theoretically, through the lymphatics.1 Treatment can consist of intravenous antibiotic therapy for 6–8 weeks, removal of implanted devices (pulse generator and leads) and vegetative material, debridement of all inflammatory tissue, abandonment of the pocket, and re-implantation (using epicardial leads or at a remote site). Removal of foreign material is often ignored because of perceived risk associated with lead extraction.1 Acute infections occurring after an Vegetation RA RA lead Figure 1. Two-dimensional echocardiogram: Transesophageal echocardiogram. Vegetative material measuring 3 cm in size by echo located in right atrium with right atrial lead present. Vegetation RV Figure 2. Two-dimensional echocardiogram: Transesophageal echocardiogram. Vegetative material migrated to right ventricle during echocardiogram. initial implantation in normal tissue are rare and usually result from some breach in surgical technique that contaminates the pocket with a virulent bacterium. An acute infection is characterized by cellulitis, a pus-producing effusion within the pocket (abscess), and in some cases, decompression into the blood, causing septicemia or discharge through the skin or both. If septicemia is present, the infection is life-threatening and demands immediate treatment.1 Infections can be caused by contamination at the time of pulse generator or lead re-implantation, or by metastatic infections. Some chronic pacemaker pockets cannot tolerate minimal levels of contamination without developing an infection. If other material is present in the pocket, such as granulation tissue or clot, the material should be debrided, drained with a closed system (e.g., Jackson-Pratt), excluded, and abandoned. Another cause of pocket infection is seeding of the pocket by bacteria from a remote infection or from a procedure such as teeth cleaning or colon polyp biopsy or resection.1 The question of coverage with prophylactic antibiotics in these situations is still mostly unanswered in the literature. The same logic used for prophylactic therapy in chronic implants also applies

Table of Contents Feed for the Digital Edition of EP Lab Digest - September 2007

The ICD Shock and Stress Management Program: Interview with Samuel F. Sears Jr., PhD Universal ECG Screening: The Advocate’s Perspective Contents Letter from the Editor Spotlight Interview: Morristown Memorial Hospital 10-Minute Interview: About the Mended Hearts and Mended Little Hearts Organizations ICD Patient Support Groups Email Discussion Group: September 2007 Technology: Only As Good As the Attitude Behind It! Electrophysiologic Management and Treatment of Chronic and Acute Cardiac Device Infection First Annual EP Lab Digest Salary Survey Events Calendar Industry News and Products

EP Lab Digest - September 2007

For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.