P1246990943MymVW

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Nonvalvular Cardiovascular DeviceRelated
Infections
AHA Scientific Statement
From the Committee on Rheumatic Fever,
Endocarditis and Kawasaki Disease, American Heart
Association

• Larry M. Baddour, Michael A. Bettmann, Ann F.
  Bolger, Andrew E. Epstein, Patricia Ferrieri,
  Michael A. Gerber, Michael H. Gewitz, Alice K.
  Jacobs, Matthew E. Levison, Jane W. Newburger,
  Thomas J. Pallasch, Walter R. Wilson, Robert S.
  Baltimore, Donald A. Falace, Stanford T. Shulman,
  Lloyd Y. Tani, Kathryn A. Taubert

Circulation. 20031082015-2031.
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Nonvalvular Cardiovascular Device-Related
Infections

• AHA scientific statement
• Circulation 20031082015-2031
• First edition
• Encyclopedic
• Excludes intravascular catheters
• Full statement available on the web at
  http//circ.ahajournals.org/cgi/content/full/108/1
  6/2015

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Nonvalvular Cardiovascular Device-Related
Infections

• Type of Devices Incidence of Infection
• IntracardiacPacemakers.. 0.13-19.9D
  efibrillators. 0.00-3.2LVADs
  . 25-70Total artificial hearts
  (TAH). To be determinedVentriculoatrial
  shunts.. 2.4-9.4Pledgets.
  RarePatent ductus arteriosus (PDA) occlusion
  devices. RareAtrial septal defect
  (ASD) and ventricular septal defect (VSD)
  closure devices. RareConduits. R
  arePatches Rare

Circulation 20031082015-2031
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Nonvalvular Cardiovascular Device-Related
Infections

• Type of Devices Incidence of Infection
• Intra-arterialPeripheral vascular
  stents RareVascular grafts, including
  hemodialysis.. 1.0-6Intra-aortic
  balloon pumps hy-related bacteremias. 1Coronary artery stents RarePatches
  1.8
• IntravenousVena caval filters.. Rare
• Closure device use

Circulation 20031082015-2031
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Nonvalvular Cardiovascular Device-Related
InfectionsAHA Scientific Statement
Two broad sections

• -- General principles
• Clinical manifestations
• Microbiology
• Pathogenesis
• Diagnosis
• Treatment
• Prevention

• -- Specific devices
• Intracardiac
• Intra-arterial
• Intravenous

Circulation 20031082015-2031
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Nonvalvular Cardiovascular Device-Related
InfectionsPathogenesis

• Pathogen virulence factors
• Adhesions (MSCRAMM)
• Biofilm
• Host response to the artificial device
• Abnormal flow
• Immunologic effects
• Physical/chemical device characteristics
• Platelet, fibrinogen attachment

Circulation 20031082015-2031
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Nonvalvular Cardiovascular Device-Related
InfectionsClinical Manifestations

• Depend on location of infected portion of device
• Local
• Systemic

Circulation 20031082015-2031
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Nonvalvular Cardiovascular Device-Related
InfectionsMicrobiology

• Staphylococcal species predominate
• Multidrug resistance, including oxacillin -
  frequent
• Aerobic gram-negative bacilli
• Pseudomonas, Acinetobacter, Serratia species
• Fungi
• Candida species - most common among fungi
• Aspergillus species - reported

Circulation 20031082015-2031
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Vascular graft site infection in a hemodialysis
patient due to methicillin-resistant S aureus.
The patient suffered bacteremia in addition to
focal skin and soft tissue changes at the graft
site, including erythema, swelling, warmth, and
pain.
Circulation 20031082015-2031
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Nonvalvular Cardiovascular Device-Related
InfectionsDiagnosis

• Laboratory
• Specimen (blood, drainage, device) cultures
• Radiologic
• Echocardiographic

Circulation 20031082015-2031
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Transesophageal echocardiographic view of the
left atrium (LA) and right atrium (RA). A
pacemaker lead (filled arrow) is seen as it
crosses the tricuspid valve. The lead is
thickened by infective material, and there is a
round mobile vegetation (open arrow) attached to
its right atrial portion.
Circulation 20031082015-2031
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Nonvalvular Cardiovascular Device-Related
Infections

• Manifestation of Infection Initial Imaging
  Modality
• Endocarditis TEEPacemakers (temporary and
  permanent)DefibrillatorsLVADsVentriculoatrial
  shuntsPledgetsASD closure devicesPatches
• Conduits PDA occlusion devices
  
• Pericarditis TTE or TEECoronary artery
  stentsPledgets

TTE or TEE
Circulation 20031082015-2031
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Nonvalvular Cardiovascular Device-Related
Infections

• Manifestation of Infection Initial Imaging
  Modality
• Endocarditis TEEPacemakers (temporary and
  permanent)DefibrillatorsLVADsVentriculoatrial
  shuntsPledgetsASD closure devicesPatches
• Conduits PDA occlusion devices
  
• Pericarditis TTE or TEECoronary artery
  stentsPledgets

TTE or TEE
Circulation 20031082015-2031
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Nonvalvular Cardiovascular Device-Related
Infections

• Manifestation of Infection Initial Imaging
  Modality
• Perivasculitis CT or MRIPeripheral vascular
  stentsVascular grafts, including
  hemodialysisAngioplasty/angiography-related
  bacteremiasCoronary artery stentsPatches
• Aneurysm or pseudoaneurysm AngiographyPledgetsC
  oronary artery stentsPatchesAngioplasty/angiogra
  phy-related bacteremiasVascular grafts,
  including hemodialysis

Circulation 20031082015-2031
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Nonvalvular Cardiovascular Device-Related
Infections

• Manifestation of Infection Initial Imaging
  Modality
• Infected thrombosis UltrasoundVena caval
  filterVascular grafts, including hemodialysis
• Pocket site infections UltrasoundPacemakers
  (permanent)DefibrillatorsLVADsTotal artificial
  hearts

Circulation 20031082015-2031
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Nonvalvular Cardiovascular Device-Related
Infections Treatment

• Antimicrobial
• Acute (induction)
• Long-term (lifelong) suppressive
• Device replacement impregnation
• Device removal
• Percutaneous
• Surgical

Circulation 20031082015-2031
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Nonvalvular Cardiovascular Device-Related
InfectionsTreatment

• Acute (induction)
• Bactericidal/fungicidal
• Parenteral
• Selection
• Based on pathogen identification/susceptibility
  testing
• Host factors
• Duration
• Variable depending on type of device and location
  of infection

Circulation 20031082015-2031
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Nonvalvular Cardiovascular Device-Related
Infections Treatment

• Long-term (lifelong) suppressive therapy
• Infected device removal - not an option
• Response to acute treatment - clinically and
  microbiologically
• Cardiovascular status - stable

Circulation 20031082015-2031
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Nonvalvular Cardiovascular Device-Related
Infections

• Primary prophylaxis
• Modeled after surgical site infection
  prophylaxis.
• Because of the low incidence of infection for
  many of the devices, without evidence-based data.
• Routinely used electrophysiological cardiac
  devices, VAD, TAH, VA shunts, pledgets, vascular
  grafts, and arterial patches.

Circulation 20031082015-2031
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Nonvalvular Cardiovascular Device-Related
Infections

• Secondary prophylaxis
• Antibiotic prophylaxis is not recommended for
  patients who undergo dental, respiratory,
  gastrointestinal or genitourinary procedures.
• It is recommended for patients if they undergo
  incision and drainage of infection at other sites
  (eg, abscess) or replacement of an infected
  device.
• It is recommended for patients with residual leak
  after device placement for attempted closure of
  the leak associated with PDA, ASD, or VSD

Circulation 20031082015-2031
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Electrophysiologic Devices

• Pacemakers
• Incidence of infection, 0.13-19.9
• Implantable cardioverter-defibrillators (ICDs)
• Incidence of infection, 0-0.8

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Electrophysiologic Devices

• Generator pocket - most common infection site
• Lead infection
• Pacemaker endocarditis
• 10 of pacemaker infections
• Most often due to generator pocket infection

Circulation 20031082015-2031
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Electrophysiologic Devices

• Infection sources
• Generator pocket contamination at implantation
• Cutaneous erosion of generator
• Hematogenous seeding (late -
  onset infection)

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Electrophysiologic Devices

• Treatment
• Duration of therapy
• No evidence-based data
• Limited to generator site - 10 days
• Lead infection - 2 to 6 weeks
• Device removal
• Paramount Reduce risk of infection relapse and
  mortality
• Device replacement
• Timing
• Varied recommendations - at least wait until
  bacteremia/fungemia cleared
• Some may not require/want device replacement

Circulation 20031082015-2031
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Electrophysiologic Devices

• Lead removal
• Greater difficulty if prolonged implantation time
• Techniques (nonsurgical)
• 81-93 successful
• 0-3.3 complications
• 0-0.8 mortality
• Locking stylet
• Telescoping sheath
• Laser sheath

Circulation 20031082015-2031
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Left Ventricular Assist Devices

• Incidence of infection 13-80
• 85 of infections occur 2 weeks after LVAD
  placement
• Mean duration of LVAD use 73 days
• Statistical association - postoperative
  hemodialysis
• Clin Infect Dis 2002341295-1300

Circulation 20031082015-2031
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Left Ventricular Assist Devices

• Three infection syndromes
• Driveline infection (most common)
• LVAD pocket site infection
• LVAD endocarditis (least common)
• Not mutually exclusive

Circulation 20031082015-2031
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Left Ventricular Assist Devices

• Immunologic effects
• Aberrant state of CD4
• T-cell activation - apoptosis
• Cutaneous anergy - recall antigens
• Lower T-cell proliferative responses
• Higher surface expression of CD95
• B-cell hyperactivity and dysregulated
  immunoglobulin synthesis

Circulation 20031082015-2031
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Left Ventricular Assist Devices

• Persistent bacteremia/fungemia not a
  contraindication to cardiac transplantation
• Transplantation is life-saving for some patients
  with uncontrollable LVAD infection

Circulation 20031082015-2031
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Total Artificial Heart

• 1980s - Jarvik-7
• Infectious/noninfectious complications
• January 2001 - FDA (USA) approval - Abiomed
• Totally implantable except external battery and
  lead to electrical inductor coil
• 10 patients (3/10/03)
• Blood clotting problems, CVAs
• No infectious complications, 7 patients
• No data, 3 patients

Circulation 20031082015-2031
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Ventriculoatrial (VA) Shunts

• VP VA use
• Incidence of infection
• Large majority within six months of placement
• CONS S. aureus
• Clinical manifestations
• Infection site dependent, virulence of organism,
  /- shunt malfunction
• Varied, though meningitis unusual
• Remember immunologic sequelae

Circulation 20031082015-2031
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Ventriculoatrial (VA) Shunts

• Diagnosis of infection
• Findings
• Presence of fever and 10 PMNs in ventricular
  fluid
• Treatment
• Two-staged exchange

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Cardiac Suture Line Pledgets

• Teflon pledgets commonly used
• Three infection syndromes
• Chest wall or epigastric involvement
• Draining sinuses, sub-q masses, pain
• Bronchopulmonary infection
• Recurrent hemoptysis, bronchiectasis, pneumonia
  with empyema
• Endocardial infection
• Bacteremia or fungemia

Circulation 20031082015-2031
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Occlusion Devices

• Patent ductus arteriosus, atrial septal defect,
  and ventricular septal defect
• Extremely rare infections (n2)
• Left atrial appendage occluders
• Pending more extensive evaluation

Circulation 20031082015-2031
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Prosthetic Vascular Grafts

• Incidence of infection 1-6 ( 5 yrs)
• Location - related
• Aortic
• Aortofemoral 1.5-2
• Infrainguinal
• Intraoperative or perioperative contamination
• Majority of cases
• Incubation period -
• Longer for indolent (CONS) pathogens

Circulation 20031082015-2031
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Prosthetic Vascular Grafts

• Purported risk factors
• Groin incisions
• Emergent surgery
• Invasive intervention (local)
• Before/after placement
• Contiguous infection
• Medical conditions (diabetes mellitus, obesity,
  chronic renal disease, immunocompromised host)

Circulation 20031082015-2031
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Prosthetic Vascular Grafts

• Clinical presentations
• Distal (extremity) infections
• Focal inflammatory changes
• Intracavitary infections
• Nonspecific, difficult to diagnose
• Magnified if years after placement
• GI bleed

Circulation 20031082015-2031
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Prosthetic Vascular Grafts

• Diagnostic modalities
• Blood cultures
• Radiologic/nuclear medicine
• CT scanning
  Sensitivity/specificity - 94/95
• MRI
• Sensitivity/specificity - 85/100
• Indium WBC, gallium - lower specificity

Circulation 20031082015-2031
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Prosthetic Vascular Grafts

• Management
• 4 tenets
• Excision of graft (foreign body)
• Wide/complete debridement of devitalized,
  infected tissue
• Maintain or establish vascular flow
• Institute prolonged systemic antimicrobial
  therapy

Circulation 20031082015-2031
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Hemodialysis Prosthetic Vascular
Grafts

• Epidemiologic factors
• Immunocompromised state
• Repetitive needle puncture at graft site
• Increased carriage of S. aureus
• 3.2 infections/100 patient-months
• CDC national surveillance system
• AV fistulas - 0.56
• Synthetic AV grafts - 1.36
• Cuffed catheters - 8.42
• Non-cuffed catheters - 11.98

Circulation 20031082015-2031
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Hemodialysis Prosthetic Vascular
Grafts

• Microbiology
• Access-related bacteremia (fistulas or grafts)
• S. aureus - 53
• CONS - 20.3
• MDR commonplace
• MRSA (VISA, VRSA)
• MRSE
• VRE

Circulation 20031082015-2031
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Hemodialysis Prosthetic Vascular
Grafts

• Management
• Complex issues, including available vascular
  access
• Old, nonfunctioning AV grafts
• Cause of delayed sepsis
• Prevention
• Mupirocin
• Increased AV fistula use
• Cryopreserved human femoral vein allograft
• Vaccines

Circulation 20031082015-2031
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Endovascular Stents and Stent-Grafts

• 400,000 patients in US undergo stent placement
  annually
• Incidence of infection
• Early (
• Predominant pathogen
• S. aureus

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Endovascular Stents and Stent-Grafts

• Complications
• Pseudoaneurysms
• Others (abscess formation, arterial necrosis,
  septic emboli, refractory sepsis, amputation
  requirement, death)
• Treatment
• Excision with extra-anatomic revascularization
• Prevention
• Primary prophylaxis - selected patients

Circulation 20031082015-2031
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Intra-aortic Balloon Counterpulsation Catheters
(IABP)

• Incidence of infection
• Wound infection
• Bacteremia
• Purported risks
• Obesity
• Emergent placement
• Surgical insertion
• Longer duration of use
• Done in areas outside OR or cath lab
• Larger diameter catheters (used in past)

Circulation 20031082015-2031
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Coronary Angiography and PTCA

• 900,000 annually worldwide
• Stents used in 80-85
• Incidence of infection
• Multiple infectious complications are described
• Bacteremia
• Mycotic aneurysm, septic arthritis, endarteritis

Circulation 20031082015-2031
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Coronary Angiography and PTCA

• Risk factors
• Brachial artery access
• Cutdown approach
• Repeat puncture (ipsilateral)
• Prolonged indwelling FA sheath
• Pressurized heparin solution
• Older age
• CHF

Circulation 20031082015-2031
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Coronary Angiography and PTCA

• Microbiology
• Staphylococcus species - Most common
• Diagnosis
• CT scan or angiography
• Persistent sepsis, septic emboli, and abdominal
  flank pain
• Treatment
• Aneurysms require resection or ligation
• Rupture propensity

Circulation 20031082015-2031
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Coronary Artery Stents

• Infection extremely rare
• Only 5 cases described in English literature
• Acute infection
• Pathogens
• S. aureus - 3 P. aeruginosa - 2
• 3/5 patients died

Circulation 20031082015-2031
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Vascular Closure Devices (VCD)

• FDA (USA) approval - 5 devices
• Favored over manual compression or compression
  devices
• Decrease time to hemostasis, increased patient
  comfort
• Incidence of infection
• Two concerns
• VCD manual compression
• Infections more severe, more difficult to treat
  (often surgical intervention)

Circulation 20031082015-2031
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Vascular Closure Devices (VCD)

• Microbiology
• S. aureus
• Methicillin-resistant
• Risk
• Diabetes mellitus?
• Prophylaxis for this group and for vascular
  access per prosthetic graft

Circulation 20031082015-2031
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Dacron Carotid Patches

• Incidence of infection 0.33 - 1.8
• Local (cervical) findings
• Early (
• Cellulitis, abscess, sepsis, pseudoaneurysm,
  massive hemorrhage, patch dehiscence
• Late
• Sinus tracts with drainage, pseudoaneurysm

Circulation 20031082015-2031
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Dacron Carotid Patches

• Microbiology
• Both viridans group streptococci and S.aureus
  predominate early late infections -
  coagulase-negative staphylococci
• Treatment
• Surgical
• Usually patch removal
• Outcome
• Overall good

Circulation 20031082015-2031
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Vena Caval Filters

• 30 years in use, 10 filters available (USA)
• Infection extremely rare
• 3 proven, 2 suspect
• Staphylococcal species - all 5 cases
• 4 with bacteremia, 2 with spondylodiscitis
• 3 cures with device removal
• 1 sepsis death, 1 long-term suppressive therapy

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Conclusions

• Medical devices enhance ability to care for
  patients with CVD
• Device infections complicate patient care
• Cure of infection may be difficult to achieve
  without device removal
• Future developments should be directed toward
• -- devices more resistant to infection
• -- antimicrobial agents with enhanced activity
• in clearing infection
• -- staphylococcal vaccines

Circulation 20031082015-2031
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