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. 2019 Nov 19;8(4):228.
doi: 10.3390/antibiotics8040228.

Pacemaker Lead Endocarditis Investigated with Intracardiac Echocardiography: Factors Modulating the Size of Vegetations and Larger Vegetation Embolic Risk during Lead Extraction

Carlo Caiati  1 , Paolo Pollice  1 , Mario Erminio Lepera  1 , Stefano Favale  1
Affiliations

Pacemaker Lead Endocarditis Investigated with Intracardiac Echocardiography: Factors Modulating the Size of Vegetations and Larger Vegetation Embolic Risk during Lead Extraction

Carlo Caiati et al. Antibiotics (Basel). .

Abstract

Lead pacemaker infection is a complication on the rise. An infected oscillating mass attached to the leads (ILV) is a common finding in this setting. Percutaneous extraction of the leads and of the device is the best curative option. However, extraction of leads with large masses can be complicated by pulmonary embolism. The aim of this study was to understand the factors associated with large ILV using a sophisticated ultrasound technique to visualize the masses, namely intracardiac echocardiography (ICE), and investigate whether larger masses induce more complications during and after extraction. Percutaneous lead extraction and peri-procedural ICE were done in 36 patients (pts) (75 ± 11 years old, 74% males). Vegetations (max dimension = 8.2 ± 4.1 mm) in the right cavity were found in 26 of them, mostly adhering to the leads. We subdivided the patients into 2 groups: with vegetation size < 1 cm (18 pts) and vegetation size ≥ 1 cm (8 pts). By univariate analysis, we found that patients in group 1 were more often taking anticoagulation therapy (p = 0.03, Phi (Phi coefficient) = -0.5, OR [odds ratio] 0.071) and had signs of local pocket infection (p = 0.02, Phi = -0.52, OR 0.059) while significantly more patients in group 2 had diabetes (p = 0.08, Phi = 0.566, OR 15); moreover the patients in group 2 showed a trend toward a more frequent positive blood culture (p = 0.08, Phi = 0.39, OR 5.8) and infection with coagulase negative staphylococci (p = 0.06, Phi = 0.46, OR 8.3). At multivariate analysis, only 3 factors (diabetes, younger age and anticoagulation therapy) were independently associated with ILV size: diabetes, associated with larger vegetations (group 2), showed the largest beta value (0.44, p = 0.008); age was inversely correlated with ILV size (beta value = -32, p = 0.038), and anticoagulation therapy (beta value = -029, p = 0.048) was more commonly associated with smaller vegetations (group 1). Larger ILV were not associated with more complications or death during or after the extraction. Conclusion: diabetes, anticoagulation therapy and age are independent predictors of lead vegetation size. The embolic potential of large ILV during extraction was modest, so ILVs >1cm are not a contraindication to percutaneous extraction of infected leads.

Keywords: embolism; infective endocarditis; intracardiac echocardiography; lead vegetations; pacemaker.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Individual value bar-graph depicting longer and shorter dimensions of lead vegetations. The two lines in the graph indicate the mean values. Veg = vegetation.
Figure 2
Figure 2
Lead infective endocarditis of smaller sizes. Example of a very small-sized mass attached to the lower-atrial portion of the lead (indicated by white arrowheads) of a single chamber PM, underscoring the high potential of ICE in visualizing even very small vegetations. This ICE “home view” projection transects the right atrium, tricuspid valve, right ventricle and ascending aorta. The vegetation (indicated by the white arrow) has a “strand” type morphology, an isoechogenic appearance, size 4 x 1 mm and high grade mobility. The patient underwent successful extraction of the infected device. (PM = pacemaker; RA = right atrium; RV = right ventricle; AO = aorta). At the bottom (in blue) electrocardiogram tracing of the patient, simultaneously recorded.
Figure 3
Figure 3
Lead infective endocarditis of larger sizes. Example of a mass attached to the terminal portion of an atrial catheter (indicated by white arrowheads) before its implantation in the right atrial appendage wall, as visualized by a specific plane orientation that transects the right atrium and right atrial appendage by means of a slight retroflexion of the probe head from a home view. This demonstrates the high potential of ICE in visualizing cardiac structures that are not accessible with other imaging modalities. The vegetation (indicated by the white arrows) has a “round shaped pedicular growth” type morphology, an iso-hyperechogenic appearance, size 14 x 8 mm, and it is attached with a sessile base to the lead with a high grade of mobility. The patient underwent successful extraction of the infected device. ICE = intracardiac echocardiography; PM: implantable cardioverter defibrillator; RA: right atrium; at the bottom (in blue) electrocardiogram tracing of the patient, simultaneously recorded.
Figure 4
Figure 4
Plot illustrating diabetes and anticoagulation before ICE interaction by a two-way between-groups ANOVA. - = finding absent; + = finding present; ICE = intracardiac echocardiography.
Figure 5
Figure 5
Plot illustrating fever and staphylococcus coagulase negative interaction in predicting vegetation size by a two-way between-groups ANOVA. - = finding absent; + = finding present; ICE = intracardiac echocardiography.
See this image and copyright information in PMC

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