Imaging of Cardiac Device-Related Infection

Abstract

Cardiac devices are frequently used in different cardiovascular conditions for the purpose of morbidity or mortality prevention. These include cardiac implantable electronic devices (CIED) like permanent pacemakers and implantable cardiac defibrillators, ventricular assistance devices (VADs), left atrial appendage occlusion (LAAO) devices like the Watchman™, atrial and ventricular septal occluders like the Amplatzer™, among others. In the past years, there has been an increase in the development of these devices as a result of a rise in the number of indications for implantation, paired with the aging and more medically complex patient population. This has led to an increase in the incidence of cardiac device-related infections, one of the most feared and serious complications which is associated with significant morbidity, mortality and financial burden. Accurate diagnosis of cardiac device-related infections is essential given the management implications which often involve removal of the infected device, removal of other prosthetic material and long-term antimicrobial therapy. Clinical and laboratory data are useful diagnostic tools but multimodality imaging is often necessary. The recently published 2020 European Heart Rhythm Association International Consensus document, which is endorsed by many expert societies, has recommended the use of multimodality imaging for the diagnosis of CIED infections. (1) This allows better disease characterization by identifying abnormal fluid collections and guiding aspiration for both diagnostic and therapeutic purposes (i.e. soft tissue ultrasound and computed tomography), evaluation for local extent of disease (i.e. transesophageal echocardiogram to evaluate for concomitant infective endocarditis), embolic manifestation of disease (i.e. computed tomography and magnetic resonance imaging) and metabolic tissue characterization (positron emission tomography and tagged white blood cell scan). (2) In addition, computed tomography (CT) allows for pre-procedural planning which has shown to be associated with better procedural outcomes.

Modern tools in cardiac imaging to assess myocardial inflammation and infection

“…Many of these CIEDs have become pillars in the management of patients with heart failure and with this increased development and usage, there has been a rise in the incidence of CIED-related infection which often require multimodality imaging for diagnostic and therapeutic guidance. 16 , 17 …”

“…However, CT is currently used to evaluate for abscesses and signs of deep infection (fat stranding) in cases of driveline infection. 16 …”

Reinfection Rates Following Cardiovascular Implantable Electronic Device Reimplementation Post-device Primary Infection

“…In these cases, the masses usually represent fibrin sheath, and do not increase the risk of infection. 21…”

Native valve, prosthetic valve, and cardiac device-related infective endocarditis: A review and update on current innovative diagnostic and therapeutic strategies

“…TEE provides a better characterization of local abnormalities and can detect valvular biofilms as small as 1 mm, whereas biofilms smaller than 5 mm have a reduced TTE sensitivity of 25% ( Erbel et al, 1988 ; Cuervo et al, 2021 ). As shown in Table 2 , TEE has a sensitivity of 67% for cardiac devices and 94% for native valves, which is 50 and 10% higher than TTE respectively ( Sekar et al, 2017 ; Doring et al, 2018 ; Koneru et al, 2018 ; Galar et al, 2019b ; Ivanovic et al, 2019 ; Slawinski et al, 2019 ; Horgan et al, 2020b ; Galea et al, 2020 ; Sifaoui et al, 2020 ; Aguilera et al, 2021 ; Jędrzejczyk-Patej et al, 2021 ). Nevertheless, the reported sensitivity of TEE for cardiac devices is limited.…”

“… CDRIE, cardiac device-related infective endocarditis; CT, computed tomography; [ 18 F]FDG, 18F-fluorodeoxyglucose; IE, infective endocarditis; NVE, native valve endocarditis; PET, positron emission tomography; PVE, prosthetic valve endocarditis; Se, sensitivity; Sp, specificity; SPECT, single photon-emission computed tomography; TEE, transesophageal echocardiography; TTE, transthoracic echocardiography; WBC, white blood cell. The values in this graph were obtained using the following references: ( Cahill and Prendergast, 2016 ; Wang A. et al, 2018 ; Bin Abdulhak et al, 2018 ; DeSimone and Sohail, 2018 ; Doring et al, 2018 ; Karchmer et al, 2018 ; Vincent and Otto, 2018 ; Galar et al, 2019a ; Ivanovic et al, 2019 ; Pettersson and Hussain, 2019 ; Slawinski et al, 2019 ; Horgan et al, 2020b ; Blomström-Lundqvist et al, 2020 ; Chambers and Bayer, 2020 ; Galea et al, 2020 ; Hubers et al, 2020 ; Aguilera et al, 2021 ; Jędrzejczyk-Patej et al, 2021 ; Rezar et al, 2021 ). …”