Implantable Cardioverter-Defibrillator and Pacemaker Infections

Implanta b l e C ard i o ver te rD e f i b r i l l a t o r an d Pacemaker Infections Ryan M. van Hoff,

MD*,

Harley P. Friedman,

MD

KEYWORDS  Cardiac implantable electronic device  Implantable cardioverter-defibrillator  Cardiac device infection  Pacemaker infection  Pocket infection  Endocarditis  Bacteremia  Explantation

HOSPITAL MEDICINE CLINICS CHECKLIST

1. Cardiac implantable electronic device (CIED) infections occur in approximately 2.5% of patients with implanted devices. Rate of infection is increasing because of expansion of indications for placement, increasing patient comorbidity, and increased rates of battery replacement with implantable cardioverter-defibrillators. 2. Increased risk for infection is associated with patient factors (diabetes, renal insufficiency, congestive heart failure, chronic obstructive pulmonary disease, malignancy, and immunosuppressive medications), device factors (more complex devices with an increased number of leads), and procedural factors (generator replacement, hematoma, operator volumes, and antibiotics). 3. The most common organisms are gram-positive cocci (coagulase negative Staphylococcus), and initial antibiotics should include vancomycin or daptomycin. 4. Clinical syndromes include pocket infection, bacteremia without valvular involvement, and cardiac device–related infectious endocarditis. 5. Initial evaluation includes microbacterial assessment for infection, early specialist consultation, and empiric antibiotics. Patients suspected to have endocarditis should undergo transesophageal echocardiography. Needle aspiration of the device pocket should be avoided because of low yield and concern of introducing an infection. CONTINUED

Department of Medicine, Geisel School of Medicine, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA * Corresponding author. E-mail address: [email protected] Hosp Med Clin - (2015) -–http://dx.doi.org/10.1016/j.ehmc.2014.11.001 2211-5943/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.

2

van Hoff & Friedman

CONTINUED

6. Gram-positive bacteremia in a patient with a CIED is associated with a 50% risk of device infection. 7. The duration of antibiotic treatment depends on the degree of lead and valve involvement. 8. Device removal is recommended in all cases of infected CIED and in all cases of staphylococcal bacteremia. 9. If reimplantation of a CIED is deemed warranted, a delay of 3 to 14 days beyond first negative blood culture is recommended depending on the extent of disease. 10. Mortality can be as high as 20% if infection progresses to endocarditis, hence early recognition and treatment are critical.

EPIDEMIOLOGY AND DEFINITIONS

Why are cardiac device infections an important topic for hospitalists? In the last 2 decades, the number of implantable cardioverter-defibrillators (ICDs) and pacemakers (hereafter referred to collectively as cardiac implantable electronic devices [CIEDs]) in the United States has increased dramatically,1 attributed to an aging population, improved technology, and an expanded range of indications for placement of these devices. With this has come an increase in the number of CIEDrelated infections, which are increasing at an even faster rate than implantation and have a significant impact on patient morbidity, mortality, and associated health care costs.1 CIED infections have therefore received increasing attention in the last decade and the American Heart Association (AHA) has released recommendations for the diagnosis and management of these infections.2 This article reviews the epidemiology and microbiology of CIED infections, predisposing risk factors, clinical presentation, diagnosis and management of patients with an infected device, and the expected clinical course and outcomes. Infections involving less common cardiac devices, such as loop recorders and ventricular assist devices, are not discussed. What are the components of a CIED? Permanent pacemakers and ICDs have 2 main components. The generator is a small electronic device that produces an electrical signal to stimulate atrial and ventricular activity, delivering pulses down wire leads that have an electrode tip that is implanted into the heart muscle. The generator is implanted under the skin (typically on the chest wall), and the leads are passed through the large veins into the right heart, terminating in the right atrium, right ventricle, or both. Cardiac resynchronization therapy (CRT) devices have an additional lead that is placed into the coronary sinus to pace the left ventricle as well. ICDs have the additional capability to recognize and shock ventricular arrhythmias. How common are CIED infections? A recent analysis of data from the Nationwide Inpatient Survey (NIS) shows a near doubling in the number of CIED implantations annually between 1993 and 2008. As seen in Fig. 1, this increase has been driven largely by the greater than 500% increase in the number of ICD implantations, although more pacemakers are also being implanted.1

ICD and Pacemaker Infections

The increase in CIED infection has outstripped the rate of increase in device implantation.1,3 Data from the NIS suggest that rate of infection was fairly constant until 2004, when it began to accelerate (Fig. 2).1 These data echo an earlier analysis of Medicare data from 1990 to 1999 and multiple single-center and multicenter retrospective studies that have suggested a disproportionate increase in infections.3–5 CAUSE AND PATHOPHYSIOLOGY

What patient, procedural, and postprocedural factors are associated with CIED infection? The expanding indications for device placement have resulted in a sicker cohort of patients who are more susceptible to infection given their burden of comorbidities. In the time frame incorporated in the NIS data analysis, the rates of heart failure, respiratory failure, chronic kidney disease, and diabetes all increased after 2004, having remained fairly constant before that time. Diabetes, renal insufficiency, congestive heart failure, chronic obstructive pulmonary disease (COPD), and malignancy all increase the risk of CIED infection.6–8 With the exception of diabetes, these comorbidities were also positively correlated with increased risk of mortality.1 Although human immunodeficiency virus/acquired immunodeficiency syndrome, autoimmune disease, and other immunocompromised states predispose patients to infection, there are no definitive data for an increased risk of CIED infection in these patients.

Fig. 1. Annual number of pacemaker and ICD implantations: 1993 to 2008. Between 1993 and 2008, overall CIED implantation increased by 96% (an average of 4.7%/y). Pacemaker implantation increased by 45%, whereas ICD implantation increased by 504%. (From Greenspon AJ, Patel JD, Lau E, et al. 16-year trends in the infection burden for pacemakers and implantable cardioverter-defibrillators in the United States 1993 to 2008. J Am Coll Cardiol 2011;58(10):1001–6; with permission.)

3

4

van Hoff & Friedman

Fig. 2. Rate of CIED infection. The annual rate of CIED infection remained constant until 2004 when there was a marked increase. The infection rate increased from 1.53% in 2004 to 2.41% in 2008 (P<.001). (From Greenspon AJ, Patel JD, Lau E, et al. 16-year trends in the infection burden for pacemakers and implantable cardioverter-defibrillators in the United States 1993 to 2008. J Am Coll Cardiol 2011;58(10):1001–6; with permission.)

Immunosuppressive medication, specifically long-term corticosteroid use, was associated with an increased risk of CIED infection (Box 1). The same is likely true for some cytotoxic agents and chemotherapy, but there are not sufficient data to state this definitively.9 Previous device infection is also a risk factor for future infections.9 Fever in the 24 hours before implantation, which might suggest active preexisting infection, is strongly associated with subsequent device infection,9 as is the presence of a temporary pacing wire6 or tunneled central venous catheter before implantation.9 ICDs have been shown to have higher rates of infection than permanent pacemakers, likely because these devices use more battery power and thus require more frequent revision for generator change and use an increased number of leads.10 Development of a hematoma at the pocket site is another common reason for device revision and has been shown in some studies to be a risk factor for subsequent infection.9 Anticoagulant therapy has been shown to be a risk factor for CIED infection, presumably because it predisposes patients to hematoma formation.6,9,11 Physician inexperience and low procedure volumes are independent risk factors for CIED infection.12 Do periprocedural antibiotics decrease the risk of CIED infection? Randomized controlled trials as early as the 1980s suggested that the use of periprocedural antibiotics dramatically decreased the rate of device infection, a finding that was supported by meta-analysis.13 Periprocedural antibiotic use receives a 1A

ICD and Pacemaker Infections

Box 1 Risk factors for CIED infection Host factors Previous device infection Placement of temporary wire before CIED Presence of central lines Immunosuppressed state Use of corticosteroids Anticoagulation Comorbidities (diabetes mellitus, congestive heart failure, chronic kidney disease, COPD, malignancy) Fever 24 hours before implantation Procedural factors Type of device (CRT or ICD >permanent pacemaker) Number of leads Device revision Lack of prophylactic antibiotics Operator inexperience

recommendation from the AHA scientific statement, which has been endorsed by the Heart Rhythm Society (HRS) and the Infectious Disease Society of America.2 What are the common organisms seen in CIED infection? Most CIED infections are by gram-positive cocci, primarily staphylococcal species, as determined from device, lead, or blood cultures. Coagulase-negative staphylococcal species are the most common organisms isolated, followed by Staphylococcus aureus, which accounts for up to half of all staphylococcal species in some series.4,6,14–17 Reporting of sensitivities shows that methicillin-resistant S aureus accounts for a significant percentage of the S aureus isolates,4,17 and methicillin resistance has also been noted in coagulase-negative staphylococcal species.14 Enterococcus and streptococcal species typically account for 3% to 9% of isolated organisms. Gram-negative rod infections also account for 3% to 9% of all cases. Polymicrobial infections, when present, are caused largely by gram-positive cocci, as mentioned earlier (Fig. 3).4,6,15,17 CLINICAL EVALUATION

How do patients with CIED infection present? Patients with suspected CIED infection typically present with one of 3 syndromes: (1) generator pocket infection, (2) bacteremia without obvious valve involvement, and (3) cardiac device–related infectious endocarditis (CDRIE). Obvious pocket infection is the most common presenting complaint for patients with CIED infection.2 Local inflammatory changes are present, including erythema, swelling, warmth, and pain. Signs of systemic infection, such as fever, fatigue, and malaise, are

5

6

van Hoff & Friedman

Fig. 3. Microbiology of permanent pacemaker/ICD infections (n 5 189). (From Sohail MR, Uslan DZ, Khan AH, et al. Management and outcome of permanent pacemaker and implantable cardioverter-defibrillator infections. J Am Coll Cardiol 2007;49(18):1851–9; with permission.)

often absent.2 In some cases the device or device lead can erode through the skin without any other signs of infection, which should be considered the equivalent of a pocket infection because direct communication implies contamination of the pocket with skin flora.2 Patients with device-related endocarditis typically present in a manner that is indistinguishable from non–device-related endocarditis,2 which can include fever, a new or changing cardiac murmur, positive blood cultures, and vegetations on echocardiography. The presence of peripheral manifestations, including both direct embolization and immune complex–related findings, should significantly raise suspicion of valve involvement and prompt further evaluation. Endocarditis is more common with S aureus infections than with other organisms. What are the initial steps in the diagnostic work-up of patients with suspected CIED infection? The determination of whether there is endocarditis or a high risk of endocarditis is a crucial component of the initial evaluation for these patients, because this determines the duration of antibiotic therapy. All patients regardless of presentation should have 2 sets of blood cultures, an electrocardiogram, a chest radiograph, and interrogation of their device. The AHA recommends evaluation of patients by specialists in cardiology and infectious disease (2a-C recommendation).2 How is the diagnosis of suspected pocket infection confirmed? In order to best direct antimicrobial therapy, efforts should be made to identify the causative organism. Blood cultures should be obtained before the initiation of

ICD and Pacemaker Infections

antimicrobial therapy (AHA 1C recommendation) to exclude endocarditis.2 Gram stain and culture of the generator pocket and lead tip should be obtained at the time of explantation (AHA 1C recommendation).2 If the initial Gram stain is negative, lead tip and tissue cultures should be held for fungal and mycobacterial culture. Empiric antibiotics should be continued because false-negative pocket culture can occur, particularly in the setting of prior antibiotic use.2 Positive lead tip culture does not imply endocarditis, because leads withdrawn through the generator pocket are likely to be contaminated.2 The AHA advisory statement recommends against aspiration of the generator pocket as part of the evaluation for CIED infection because of low yield and the risk of introducing infection (AHA 3C recommendation).2 How is the diagnosis of suspected device-related endocarditis confirmed? If infectious endocarditis is suspected or bacteremia is confirmed in a patient with a cardiac device, it is important to determine whether and to what extent the cardiac device is involved. Device involvement in the setting of bloodstream infection is common: about 50% in 2 series of patients with CIEDs and S aureus bacteremia.18,19 There are limited data on bloodstream infections with nonstaphylococcal organisms, which seem to be less frequently associated with CIED infection.17,19,20 Gram-negative bloodstream infections typically have another identifiable source and are not often associated with device involvement.18 Transesophageal echocardiography (TEE) is recommended for all adult patients in whom endocarditis is suspected, even if prior transthoracic echocardiogram has determined that a vegetation is present (AHA 1b recommendation). TEE is superior in determining the presence of vegetations and the location on the lead or on a valve, as well as identifying potential sequelae such as abscess or left-sided involvement.21 As many as 1 in 3 patents with CDRIE also have involvement of either a native or prosthetic valve.15 Any patient with confirmed or suspected pocket infection who is found to have bloodstream infection should have a TEE to evaluate the leads and valve, as should those patients who have recently been on antibiotics, because cultures are likely to be falsely negative (AHA 1C recommendation).2 If TEE is negative but suspicion remains high for CDRIE, a repeat TEE in 7 to 10 days can be considered, as recommended in the European guidelines for infectious endocarditis.22 MANAGEMENT: ANTIBIOTICS

When should empiric antibiotics be started? Which agents should be used? The AHA scientific statement includes a class I recommendation that “the choice of antimicrobial therapy should be based on the identification and in vitro susceptibility results of the infecting pathogen” (level of evidence, B).2 Two sets of blood cultures should be drawn on presentation as well as device pocket and lead tip Gram stain and culture at the time of device removal. As soon as initial cultures are obtained, empiric therapy should be initiated. Vancomycin is recommended as the empiric antibiotic of choice given that gram-positive organisms account for about 90% of CIED infections and methicillin resistance is common.2 If the patient has a vancomycin allergy, daptomycin is an appropriate alternative.23 If signs of systemic illness are present and another source of infection is possible, gram-negative coverage with an antipseudomonal agent may be warranted until an organism is identified.23

7

8

van Hoff & Friedman

How long should patients remain on antibiotics? The optimal duration for antimicrobial therapy has not been determined in randomized trials and recommendations from the AHA are based largely on expert opinion. The duration of antibiotics should be counted from the day of device explantation and is determined by the extent of infection. The AHA endorsed an algorithm in their 2010 scientific statement that was adapted from Sohail and colleagues4 (Fig. 4). The use of TEE features prominently in differentiating the degree of lead and valve involvement, which in turn informs the duration of antibiotic therapy. There are no data on the safe transition from parenteral to oral antibiotics. This transition can be considered once organism susceptibility is known, but some experts recommend parenteral antibiotics for the duration of treatment.23 MANAGEMENT: DEVICE REMOVAL AND REPLACEMENT

Which patients should have their device removed? Removal of the complete device is recommended in all cases of confirmed CIED infection,2 including lead removal in cases of isolated pocket infection without evidence of lead or systemic involvement and of the device in cases of endocarditis in the absence of pocket involvement, because relapse rates are higher with retained hardware.24,25 Lead extraction should be performed at an institution with familiarity in the procedure and with cardiothoracic surgery available in the event of complication such as tamponade, hemothorax, and lead migration, although these are infrequent occurrences.2,17

Fig. 4. Mayo Clinic algorithm of cardiac device infection management: approach to management of adults with permanent pacemaker (PPM)/ICD infection. This algorithm applies only to patients with complete device explantation. a Duration of antibiotics should be counted from the day of device explantation. (From Sohail MR, Uslan DZ, Khan AH, et al. Management and outcome of permanent pacemaker and implantable cardioverterdefibrillator infections. J Am Coll Cardiol 2007;49(18):1851–9; with permission.)

ICD and Pacemaker Infections

Surgical removal should be used when attempts at percutaneous removal have failed, and can be considered when vegetations exceed 2 cm, although evidence that this approach reduces embolization is lacking.4,24,26 Does the device need to be removed if patients have bacteremia without overt CIED infection? Because of the high incidence of device involvement in patients with occult staphylococcal bacteremia, the AHA and HRS both recommend that these patients also undergo device removal even if device involvement cannot be proved.2 There are few data to support device removal in patients with gram-negative bacteremia, which is rarely caused by device infection.18 For relapsing infections caused by an identified source requiring long-term antibiotics, CIED removal is not indicated.2 Are there any patients with device infection who do not need the device removed? The device does not need to be removed if the infection is determined to be isolated to the skin or incision overlying the device in the postoperative period.2 In some patients who are not candidates for removal, as in the setting of advanced illness or refusal, long-term suppressive antibiotics can be considered provided a pathogen has been identified and shown to respond to tailored therapy (AHA class IIb recommendation).2 How are patients managed after their device has been removed? As many as one-half of all patients no longer have an indication for placement of a CIED.4 If ongoing need is determined to be present, the infected device should not be removed until a plan for replacement has been established, especially in patients who are pacemaker dependent, such as those with a history of complete heart block. These patients require bridging with a temporary pacemaker until they are able to receive a permanent replacement.2 The use of active fixation leads with these temporary devices (ie, leads placed under fluoroscopy and anchored to the myocardium in a similar manner to permanent leads) has been shown to decrease the complications associated with temporary devices.27 Replacement devices should be placed on the contralateral side from the previous device, and if this is not possible they can also be placed in the abdomen with tunneled venous leads.2 When can a new device be reimplanted? There are no prospective data regarding the timing around reimplantation of CIEDs after infection, and guidelines are based primarily on retrospective data and expert opinion.2,28 The approach to reimplantation is outlined in the algorithm from the AHA scientific statement (Fig. 5), and the timing depends largely on the extent of the infection.2 In contrast, other experts have recommended waiting at least 24 hours after device removal or first negative blood culture,29 in line with recommendations proposed by the European Society for Cardiology.22 OUTCOMES

What is the expected morbidity and mortality for patients with CIED infection? Mortalities in CIED infection are significant. In patients with isolated pocket infection, mortality is estimated around 5% (higher if there is bloodstream infection), and as

9

10

van Hoff & Friedman

high as 20% in patients with device-related endocarditis.30,31 Patients with CDRIE have a higher mortality than patients with infective endocarditis without a device.30 Risk factors for mortality include positive blood cultures, renal failure, valve involvement, abnormal right ventricular function, and pulmonary or systemic embolization.15,32 The importance of expeditious device removal is emphasized by patients with delayed removal of device having significantly higher rates of mortality, driven primarily by infection and complications of infection such as sepsis and multisystem organ failure.28 Potential complications of incompletely treated infection include local spread of infection such as chest wall abscess and right-sided endocarditis, and metastatic spread of infection to the lungs, left heart, and distant organs.2 CLINICAL GUIDELINES

Sohail MR, Uslan DZ, Khan AH, et al. Management and outcome of permanent pacemaker and implantable cardioverter-defibrillator infections. J Am Coll Cardiol 2007;49(18):1851–9. Baddour LM, Epstein AE, Erickson CC, et al. Update on cardiovascular implantable electronic device infections and their management: a scientific statement from the American Heart Association. Circulation 2010;121(3):458–77. PERFORMANCE IMPROVEMENT

At time of implantation  Prophylactic antibiotics have produced a marked decrease in device infection.  Higher procedure volumes are associated with a decreased risk of infection.  The presence of intravenous catheters, pacing wires, and other transcutaneous intravascular structures increases the likelihood of subsequent infection and should be minimized.

Fig. 5. Mayo Clinic algorithm of cardiac device infection management: guidelines for reimplantation of new device in patients with PPM/ICD infection. (From Sohail MR, Uslan DZ, Khan AH, et al. Management and outcome of permanent pacemaker and implantable cardioverter-defibrillator infections. J Am Coll Cardiol 2007;49(18):1851–9; with permission.)

ICD and Pacemaker Infections

Infection prevention  Prophylactic antibiotics for dental and minor surgical procedures are not recommended for patients with CIEDs.  Urgent and early initiation of antibiotics should be started in patients with suspected bacteremia.  Aggressive surveillance for CIED infection is indicated for patients with implanted devices and bacteremia from other sources.  Patients with staphylococcal bacteremia from another source have a 50% likelihood of device infection; removal of the device should be strongly considered. At the time of diagnosis of infection  Early consultation with specialists in infectious disease and cardiology is recommended.  Explantation should be performed by experienced operators with adequate surgical support. REFERENCES

1. Greenspon AJ, Patel JD, Lau E, et al. 16-year trends in the infection burden for pacemakers and implantable cardioverter-defibrillators in the United States 1993 to 2008. J Am Coll Cardiol 2011;58(10):1001–6. 2. Baddour LM, Epstein AE, Erickson CC, et al. Update on cardiovascular implantable electronic device infections and their management: a scientific statement from the American Heart Association. Circulation 2010;121(3):458–77. 3. Cabell CH, Heidenreich PA, Chu VH, et al. Increasing rates of cardiac device infections among Medicare beneficiaries: 1990-1999. Am Heart J 2004;147(4): 582–6. 4. Sohail MR, Uslan DZ, Khan AH, et al. Management and outcome of permanent pacemaker and implantable cardioverter-defibrillator infections. J Am Coll Cardiol 2007;49(18):1851–9. 5. Voigt A, Shalaby A, Saba S. Continued rise in rates of cardiovascular implantable electronic device infections in the United States: temporal trends and causative insights. Pacing Clin Electrophysiol 2010;33(4):414–9. 6. Klug D, Balde M, Pavin D, et al. Risk factors related to infections of implanted pacemakers and cardioverter-defibrillators: results of a large prospective study. Circulation 2007;116(12):1349–55. 7. Mittal S, Shaw RE, Michel K, et al. Cardiac implantable electronic device infections: incidence, risk factors, and the effect of the AigisRx antibacterial envelope. Heart Rhythm 2014;11(4):595–601. 8. Bloom HL, Constantin L, Dan D, et al. Implantation success and infection in cardiovascular implantable electronic device procedures utilizing an antibacterial envelope. Pacing Clin Electrophysiol 2011;34(2):133–42. 9. Sohail MR, Uslan DZ, Khan AH, et al. Risk factor analysis of permanent pacemaker infection. Clin Infect Dis 2007;45(2):166–73. 10. Borleffs CJ, Thijssen J, de Bie MK, et al. Recurrent implantable cardioverterdefibrillator replacement is associated with an increasing risk of pocket-related complications. Pacing Clin Electrophysiol 2010;33(8):1013–9. 11. Lekkerkerker JC, van Nieuwkoop C, Trines SA, et al. Risk factors and time delay associated with cardiac device infections: Leiden device registry. Heart 2009; 95(9):715–20. 12. Al-Khatib SM, Lucas FL, Jollis JG, et al. The relation between patients’ outcomes and the volume of cardioverter-defibrillator implantation procedures performed

11

12

van Hoff & Friedman

13. 14.

15.

16.

17.

18.

19.

20.

21. 22.

23.

24. 25. 26.

27.

28.

by physicians treating Medicare beneficiaries. J Am Coll Cardiol 2005;46(8): 1536–40. Da Costa A, Kirkorian G, Cucherat M, et al. Antibiotic prophylaxis for permanent pacemaker implantation: a meta-analysis. Circulation 1998;97(18):1796–801. de Oliveira JC, Martinelli M, D’Orio Nishioka SA, et al. Efficacy of antibiotic prophylaxis before the implantation of pacemakers and cardioverter-defibrillators: results of a large, prospective, randomized, double-blinded, placebo-controlled trial. Circ Arrhythm Electrophysiol 2009;2(1):29–34. Athan E, Chu VH, Tattevin P, et al. Clinical characteristics and outcome of infective endocarditis involving implantable cardiac devices. JAMA 2012;307(16): 1727–35. Nery PB, Fernandes R, Nair GM, et al. Device-related infection among patients with pacemakers and implantable defibrillators: incidence, risk factors, and consequences. J Cardiovasc Electrophysiol 2010;21(7):786–90. Sopena B, Crespo M, Beiras X, et al. Individualized management of bacteraemia in patients with a permanent endocardial pacemaker. Clin Microbiol Infect 2010; 16(3):274–80. Uslan DZ, Sohail MR, St Sauver JL, et al. Permanent pacemaker and implantable cardioverter defibrillator infection: a population-based study. Arch Intern Med 2007;167(7):669–75. Chamis AL, Peterson GE, Cabell CH, et al. Staphylococcus aureus bacteremia in patients with permanent pacemakers or implantable cardioverter-defibrillators. Circulation 2001;104(9):1029–33. Camus C, Leport C, Raffi F, et al. Sustained bacteremia in 26 patients with a permanent endocardial pacemaker: assessment of wire removal. Clin Infect Dis 1993;17(1):46–55. Evangelista A, Gonzalez-Alujas MT. Echocardiography in infective endocarditis. Heart 2004;90(6):614–7. Habib G, Hoen B, Tornos P, et al. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): the Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the International Society of Chemotherapy (ISC) for infection and cancer. Eur Heart J 2009;30(19):2369–413. Dababneh AS, Sohail MR. Cardiovascular implantable electronic device infection: a stepwise approach to diagnosis and management. Cleve Clin J Med 2011;78(8):529–37. Field ME, Jones SO, Epstein LM. How to select patients for lead extraction. Heart Rhythm 2007;4(7):978–85. Margey R, McCann H, Blake G, et al. Contemporary management of and outcomes from cardiac device related infections. Europace 2010;12(1):64–70. Wilkoff BL, Love CJ, Byrd CL, et al. Transvenous lead extraction: Heart Rhythm Society expert consensus on facilities, training, indications, and patient management: this document was endorsed by the American Heart Association (AHA). Heart Rhythm 2009;6(7):1085–104. Braun MU, Rauwolf T, Bock M, et al. Percutaneous lead implantation connected to an external device in stimulation-dependent patients with systemic infection–a prospective and controlled study. Pacing Clin Electrophysiol 2006;29(8):875–9. Le KY, Sohail MR, Friedman PA, et al. Impact of timing of device removal on mortality in patients with cardiovascular implantable electronic device infections. Heart Rhythm 2011;8(11):1678–85.

ICD and Pacemaker Infections

29. Gaynor SL, Zierer A, Lawton JS, et al. Laser assistance for extraction of chronically implanted endocardial leads: infectious versus noninfectious indications. Pacing Clin Electrophysiol 2006;29(12):1352–8. 30. Le KY, Sohail MR, Friedman PA, et al. Clinical predictors of cardiovascular implantable electronic device-related infective endocarditis. Pacing Clin Electrophysiol 2011;34(4):450–9. 31. Tarakji KG, Chan EJ, Cantillon DJ, et al. Cardiac implantable electronic device infections: presentation, management, and patient outcomes. Heart Rhythm 2010; 7(8):1043–7. 32. Baman TS, Gupta SK, Valle JA, et al. Risk factors for mortality in patients with cardiac device-related infection. Circ Arrhythm Electrophysiol 2009;2(2):129–34.

13