No abstract

Aims: A nested case-control study of 75 patients with cardiac device infections (CDI) and 75 matched controls was conducted to evaluate time course, risk factors, culture results and frequency of CDI. Methods and results: CDI occurred in 75/3410 (2.2%) device implantation and revision procedures, performed between 2000 and 2007. The time delay between device procedure and infection ranged from 0 to 64 months (mean 14 (SD 16)), 21 patients (28%) had an early infection (,1 month), 26 (35%) a late infection (1-12 months) and 28 (37%) a delayed infection (.12 months). Of interest, 18 (24%) patients presented with an infection .24 months after the device-related procedure. Time delay until infection was significantly shorter when cultures were positive for micro-organisms compared to negative cultures (8 (12) vs 18 (18) months, p = 0.03). Pocket cultures in delayed infections remained more often negative (61% vs 23%, p = 0.01). Independent CDI risk factors were: device revision (odds ratio (OR) 3.67; 95% confidence interval (CI), 1.51 to 8.96), renal dysfunction defined as glomerular filtration rate ,60 ml/min (OR 4.64; CI, 1.48 to 14.62) and oral anticoagulation use (OR 2.83; CI 1.20 to 6.68). Conclusion: CDI occurred in 2.2% of device procedures, with 24% occurring more than two years after the devicerelated procedure. Renal dysfunction, device revisions and oral anticoagulation are potent risk factors for CDI.With expanding evidence-based indications for the implantation of permanent pacemakers, implantable cardioverter defibrillators (ICDs) and cardiac resynchronisation therapy devices (CRTs) the number of device-related procedures have increased rapidly over the past decade. 1 There are indications that the rate of cardiac device infections (CDI) has increased and that this outpaced the increase in implantation rate. 1 Reported CDI rates vary between 0.5% and 5.1%. 2-5 CDI is a serious and potentially life-threatening complication of cardiac device therapy, associated with significant morbidity and mortality usually requiring explantation of the device and lead system. Furthermore device infection results in prolonged hospital stay which is associated with significant costs. The average economic cost of CDI treatment has been estimated at $50 000 (£34 000; J39 400) per patient. 6 7 Although cardiac device therapy improves the outcome in different patient groups, CDI may negatively influence the risk-benefit ratio, especially in primary prevention patients. 1 Risk factors, although under debate, associated with CDI include sex, advanced age, diabetes mellitus, depressed immunity, number of operators, total number and duration of device-related procedures and oral anticoagulation therapy. 8 9 Moreover, CDI can occur shortly after a devicerelated procedure, but may also occur after several months and even after years. 2 Until now little is known about the occurrence and risk factors of CDI late after a device-related procedure. 10 In addition, exact data of infection rates and risk factors in acute and delayed inf...

In a large cohort of ICD patients, inappropriate shocks were common. The most important finding is the association between inappropriate shocks and mortality, independent of interim appropriate shocks.

The complication rate in patients implanted with an S-ICD or TV-ICD was similar, but their nature differed. The S-ICD reduced lead-related complications significantly, at the cost of nonlead-related complications. Rates of appropriate and inappropriate shocks were similar between the 2 groups.

Current clinical guidelines for the management of radiotherapy patients having either a pacemaker or implantable cardioverter defibrillator (both CIEDs: Cardiac Implantable Electronic Devices) do not cover modern radiotherapy techniques and do not take the patient’s perspective into account. Available data on the frequency and cause of CIED failure during radiation therapy are limited and do not converge. The Dutch Society of Radiotherapy and Oncology (NVRO) initiated a multidisciplinary task group consisting of clinical physicists, cardiologists, radiation oncologists, pacemaker and ICD technologists to develop evidence based consensus guidelines for the management of CIED patients. CIED patients receiving radiotherapy should be categorised based on the chance of device failure and the clinical consequences in case of failure. Although there is no clear cut-off point nor a clear linear relationship, in general, chances of device failure increase with increasing doses. Clinical consequences of device failures like loss of pacing, carry the most risks in pacing dependent patients. Cumulative dose and pacing dependency have been combined to categorise patients into low, medium and high risk groups. Patients receiving a dose of less than 2 Gy to their CIED are categorised as low risk, unless pacing dependent since then they are medium risk. Between 2 and 10 Gy, all patients are categorised as medium risk, while above 10 Gy every patient is categorised as high risk. Measures to secure patient safety are described for each category. This guideline for the management of CIED patients receiving radiotherapy takes into account modern radiotherapy techniques, CIED technology, the patients’ perspective and the practical aspects necessary for the safe management of these patients. The guideline is implemented in The Netherlands in 2012 and is expected to find clinical acceptance outside The Netherlands as well.