Risk factors and time delay associated with cardiac device infections: Leiden device registry

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...

Pocket creation in the prepectoral subfascial position for the implantation of a cardiac implantable electrical device

“…Because the creation of such pockets requires deep dissection, traumatic injury of small vessels or nerves, accidental bleeding, or postoperative hematoma may occur. Further, hematomas within the pockets, complicating CIED placement, have been identified as risk factors for pocket infections and have been associated with CIED replacement [9]. Thus, it is desirable to prevent hematoma formation during the procedure.…”

Cardiac implantable electronic devices in end-stage renal disease patients: preservation of central venous circulation

“…However, patients with moderate to severe renal disease exhibit higher device infection rates as compared to the general population [24][25][26]. Cardiac device infection can be a potentially life-threatening if untreated and can also lead to endocarditis [27,28].…”

“…For these reasons, the transvenous route has become the most frequently used method for implantation of CIEDs. However, the use of the transvenous CIEDs can be associated with significant complications in chronic HD patients including central venous stenosis, tricuspid regurgitation (TR), and device infection [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31].…”

Cardiac Implantable Electronic Device Infection in Patients at Risk

“…24 hours before the implantation, 7 anticoagulation 17 and steroid use. 19 Important device-related risk factors include device revision or upgrade, 8 the use of more than two pacing leads and the need for early pocket re-exploration.…”