Lead-associated endocarditis LAE is usually a late lead-associated infection >6 months from time of the procedure, whereas the early lead-associated infections... tend to present clinica
Trang 1Implantable cardiac electronic devices (ICEDs) constitute permanent
pacemakers (PPMs) and implantable cardioverter defibrillators (ICD); cardiac resynchronization therapy devices are rarely used in children Lead-associated endocarditis (LAE) is usually a late lead-associated infection (>6 months from time of the procedure), whereas the early lead-associated infections (<6 months from the time of procedure) are usually pocket infections There is a UK 2015 guideline for the management of ICED infections.10
Incidence.
ICED-IE constitutes 10% of all adult IE cases,17,225,226 and this has gradually increased from being 1% in 1987–1993.226 The incidence at which ICEDs in adults become infected is approximately 2%, or 4.82/1000 device days227; the incidence in ICDs is higher than in PPMs and for redo procedures higher than the initial one Rising incidences have also been reported, but this has to be carefully adjusted to the constantly rising number of implantations.228,229
Causative agents.
More than 80% are gram-positive IE, less than 20% are gram-negative IE It is
the only IE type where coagulase-negative Staphylococcus–related cases are of similar proportion as S aureus–related cases.
The clinical presentation is known to be atypical, and diagnosis may be significantly delayed.230
■ Patients presenting at less than 1 year from the
implantation are more likely to have predominant local symptoms, whereas those greater than 1 year
■ Vegetations on leads were frequently observed in
echocardiography is indicated in all cases of pocket infections.
■ Patients with vegetation less than 1 cm more often
Trang 2tend to present clinically as pocket infection, whereas those with vegetation greater than 1 cm as systemic infection; CONS cases of IE are associated with
Echocardiography can be negative in higher percentages than in the other types of IE,234 and transesophageal echocardiography might be indicated slightly more often PET/CT has made significant improvement to the positive yield in diagnostic process and improved the sensitivity of the modified Duke
criteria.36–38
Risk factors for ICED-IE varied between studies235–237 and are described as pyrexia 24 hours before the implantation, preceding temporary pacing,
reintervention, diabetes, use of more than one lead, and larger hematoma
Outcome.
Mortality is high in cases of antibiotic management only and may be greater than 30% Complete ICED system removal within 2 weeks from LAE diagnosis
improves significantly outcomes to a mortality of approximately 5%238,239 to become similar to those without IE.240 Surgery carries high risk Transcatheter removal has become the preferred approach.241–243 The vacuum suction of
thrombus prior to removal has been established in adults but has not been
available for children Open surgical removal should be reserved for large (>20 mm) lead-associated vegetations or when surgery is indicated for other reasons Results for children with LAE are likely to be much more favorable than these for adults and should be published separately
Neonatal Infective Endocarditis
■ Most often related to catheters
■ Systemic hypotension
■ Signs of generalized sepsis (feeding difficulties,
respiratory distress or apnea, tachycardia)
■ Particularly prone to septic embolization (focal
Trang 3development of satellite infections (meningitis,
osteomyelitis, pneumonia)
■ Higher proportion of fungal IE
■ Osler nodes, Roth spots, Janeway lesions, and
splinter hemorrhages are not seen
Prophylaxis
Prophylaxis for Dental Procedures.
IE prophylaxis has dramatically been changed since 2002 French, 2007 AHA,3
2008 UK National Institute of Clinical Excellence (NICE)244/update 2016,5 and
2009 ESC/update 20151 recommendations that reduced the indications for IE prophylaxis as per the lack of scientific evidence for its efficacy being widely accepted The basis to support this recommendation is:
■ There is no consistent association between having
an interventional procedure, dental or nondental, and the development of IE.
■ Regular toothbrushing almost certainly presents a greater risk of IE than a single dental procedure
because of repetitive exposure to bacteremia with oral flora.
■ The clinical effectiveness of antibiotic prophylaxis
is not proven.
■ Antibiotic prophylaxis against IE for dental
procedures may lead to a greater number of deaths through fatal anaphylaxis than a strategy of no
antibiotic prophylaxis and is not cost effective.