1. Pacemaker and Lead Infections Alpay Celiker MD. Hacettepe University Ankara, Turkey Case Based Tutorial Heart Rhythm 2006. May 17-20 Boston, USA

2. Birth 1988 September 1990 Surgery for FT September 1990 VVI Epicardial Pace June 1994 VVIR Transvenous Pace September 2000 Battery Change Abandoned Lead Removal Insertion of a new lead April 2001 Lead Fracture February 2005 Fever Sensing&Capture Problem Case Report

3. Heart Rhythm 2006. May 17-20 Boston, USA Clinical Findings History: − Fever − Chills − Vomiting − Blurred vision − Artralgia Physical Examination − Fever: 38 0 C − Pulse: 100 bpm, BP: 110/70 mm Hg − Grade 2-3/6 systolic ejection murmur − Mild early diastolic murmur − No local sign of infection

4. Heart Rhythm 2006. May 17-20 Boston, USA

5. Laboratory I Hb: 13 gr/dl WBC: 27000 /mm 3 Differential count: Unremarkable Platelet: 198.000/mm 3 ESR: 10 mm/hour, CRP: 5.4 mg/dl Normal renal and liver function tests Urine: Trace protein, fine granular cylinders

6. Heart Rhythm 2006. May 17-20 Boston, USA Laboratory II Blood Culture (Several times): Negative Brain CT: Normal Transthoracic Echo: Bad echo window − TR: Grade II, V: 3.2 m/second − Pulmonary Gradient 16 mm Hg − Pacemaker electrodes in right ventricle cavity − No visible thrombus or vegetation

7. Heart Rhythm 2006. May 17-20 Boston, USA Treatment Vancomycine Gentamycine (7 days) Persisting Fever Cardiac Surgery Lead Removal Ceftriaxone Gentamycine (3 days) TOE Vegetations on lead Fever

8. Heart Rhythm 2006. May 17-20 Boston, USA

9. TOE A multilobular vegetation attached to the old abandoned lead near the tricuspid valve Moderate tricuspid regurgitation

10. Heart Rhythm 2006. May 17-20 Boston, USA Result Surgical removal under CPB Epicardial pacing with a VVIR pacing system Lead Culture: S. Epidermidis Long term treatment with vancomycin Discharge after 4 weeks following surgery No recurrence of infection at 14 months of follow-up.

11. Heart Rhythm 2006. May 17-20 Boston, USA

14. Pacing System Complications Infection Lead malfunction Venous occlusion

15. Heart Rhythm 2006. May 17-20 Boston, USA Pacing System Infection Localized or superficial infection − Localized pain, swelling − Purulent discharge Deep infection − Fever − Purulent discharge − Pulmonary thromboembolism − Recurrent pulmonary infection − Sepsis

16. Heart Rhythm 2006. May 17-20 Boston, USA Pediatric Pacemaker Infections* Perioperative Infections (before discharge): − Superficial 1,2 % − Deep 0,2 % Early Pacemaker Infections (< 60 days)Early Pacemaker Infections (< 60 days) − Superficial 3,1 % − Deep 1,2 % Late Pacemaker Infections − Superficial 0,5 % − Deep 0,7 % Staphylococcus species were isolated in 44 % Increased Risks − Reintervention − Down syndrome − Subcutaneous  preperitoneal pocket * Cohen et al J Thorac Cardiovasc Surg 2002; 124.

17. Heart Rhythm 2006. May 17-20 Boston, USA Pacing System Infection Laboratory − Complete blood count with differential analysis, eritrosit sedimentation rate − CRP, circulating immun complexes − Blood and tissue culture − Gram staining − ECG and X-ray − Echocardiographic exam − Pulmonary perfusion sintigraphy

18. Heart Rhythm 2006. May 17-20 Boston, USA Deep Infection Echo is very important for − to reveal intracardiac masses Vegetations Strands Abcess − to determine the degree of tricuspid regurgitation

19. Heart Rhythm 2006. May 17-20 Boston, USA Deep Infection Transthoracic versus Transosephageal Echo TTE Limitations Bad echo image (previous cardiac operations) Lead related confusing echo signals Inability to see strands TOE Pacemaker Lead Infection n=23 Positive TTE 7/23 (30 %) Positive TOE 21/23 (91 %) Victor et al. Heart 1999; 81

20. Heart Rhythm 2006. May 17-20 Boston, USA Treatment Localized Infection − Intravenous and oral antibiotics − Local debridman − Infrequently pacing system removal Fever and Positive Culture with Negative TOE − Prolonged antibiotic usage

21. Heart Rhythm 2006. May 17-20 Boston, USA

22. Deep Infection Pacing system removal mandatory − Interventional − Surgical − Hybrid procedures Antibiotics − >2 weeks intravenously −  6 weeks total

23. Heart Rhythm 2006. May 17-20 Boston, USA Treatment Choices Surgery − Large vegetations (> 10mm) − Abcess formation − Broken lead − Abandoned old leads − Concomitant surgery need Intervention − Small vegetations − Strand formation − Lead amenable to extraction

24. Heart Rhythm 2006. May 17-20 Boston, USA Interventional Treatment Simple traction Lead locking systems Laser or RF systems Femoral access

25. Heart Rhythm 2006. May 17-20 Boston, USA Chest 2003; 12

26. Heart Rhythm 2006. May 17-20 Boston, USA Europace 2006; 6

27. Heart Rhythm 2006. May 17-20 Boston, USA Conclusions I Pacing system infection is not rare in children Deep infection involving the lead may present as purulent discharge and/or endocarditis or systemic infection TOE is the main diagnostic tool for the diagnosis of lead vegetations

28. Heart Rhythm 2006. May 17-20 Boston, USA Conclusions II Pacing system removal is needed to cure the deep infection Removal may be done with lead extraction methods in the majority of patients Surgery is still mandatory in some patients

29. Heart Rhythm 2006. May 17-20 Boston, USA PEDIRHYTHM III 24-27TH OCTOBER ISTANBUL, TURKEY