Vegetation Size

Abstract

The descriptive analysis in this issue of the Journal by Grammes et al.(1) of their percutaneous rhythm devicelead extraction experience in 100 infective endocarditis patients with 216 leads (average lead age 4 years) and further complicated by large intracardiac vegetations is admirable, instructive, and thought provoking. The data primarily come from prospectively maintained lead extraction records, plus retrospective assessment of the pre-and post-extraction course during a 16-year time frame. See page 886All 100 patients and their infected leads were complicated by intra-cardiac vegetations ranging in size from 0.2 to 4.0 cm (mean 1.6 cm), all fulfilling the modified Duke criteria (2) for possible or definite rhythm device-related infective endocarditis. The principle management team included the pacemaker electrophysiology extraction members, anesthesiologists, and infectious disease consultants, and cardiac surgeons only when new epicardial lead systems were required in 2 patients. Throughout the 16 years of this retrospective analysis, a generally consistent therapeutic approach was followed by this center that included local and tertiary referral patients. The authors' lead extraction approach included the following: 1) attempted identification of the infecting organism with cultures; 2) pre-procedure esophageal echo imaging (transesophageal echocardiography) for identification of vegetations from in-house or referral sources, plus localizing and sizing of right-sided heart vegetations; 3) infectious disease service management of antibiotics to suppress bacteremia; 4) extraction of all implanted pulse generators and intravascular leads using percutaneous extraction tools and techniques of the day, regardless of vegetation size or location; 5) post-lead extraction/transvenous pacing, antibiotics, medical treatment of progressive heart failure and overwhelming sepsis, plus subsequent reimplantation of new, usually transvenous, implanted pulse generator-lead systems when appropriate.The authors noted that extraction times were equal to (or shorter for infected leads) lead extraction times for 2,004 noninfected leads. We believe this is a valid observation, but rarely documented in print or timed, and is assumed to be due to localized bacterial breakdown of fibrosis and tissue adjacent to the lead, and not necessarily related to vegetation.Size of the vegetations did not alter the authors' preprocedure evaluation, extraction techniques, and timing, nor did they find that vegetations have a significant effect on acute procedure mortality. Two patients did have acute pulmonary and hemodynamic symptoms attributed to vegetation embolus; both stabilized in a few hours. Hospital mortality and 30-day mortality totaled 10 patients (10%), and no deaths were directly related to a pulmonary vegetation embolus; however, most deaths were attributed to progressive heart failure and overwhelming sepsis. One patient did have procedure-related severe traumatic tricuspid insufficiency. Late mortality was 19%, although some pat...

Clinically Focused Review of Diagnosis and Treatment of Cardiovascular Implantable Electronic Device Infections

“…Transoesophageal echocardiography (TEE) should be carried out in patients who are suspected to infection or those with confirmed infection, as this is the most effective method in determining the presence of bacteria in valvular vegetations or vegetations along the leads (21,22). TEE remains the ideal technique for the evaluation of vegetation size that is important to determine the optimal method of removing the infected leads (23). Table 1 illustrates the American Heart Association guidelines on the diagnosis of CIED infections.…”