Pacemaker Endocarditis: Clinical Features and Management

Background

• Pacemaker-related endocarditis is increasing, while diagnosis and management remain difficult.

• Objective: Evaluate clinical features and management of endocarditis after pacemaker (PM) or cardioverter defibrillator (ICD) implantation.

Methods

• Analyzed hospital courses of 60 consecutive patients (48 men, mean age $68 \pm 12$ years) admitted for PM (n = 59) or ICD (n = 1) endocarditis between 1998 and 2004.

Results

• Common symptoms: Fever (78%), asthenia (65%), local symptoms (35%).

• Positive cultures: 53 cases (Staphylococcus 89%).

• Pulmonary embolism: 16 patients (27%).

• Vegetations: mean size $15.2 \pm 8$ mm (range 5 to 35 mm) in 54 cases (90%). Detected via:

  • Transthoracic echocardiography (TTE) in 26 cases (43%).

  • Transesophageal echocardiography (TEE) in 50 cases (89% of the 56 patients who had TEE).

• Device removal:

  • Surgical (n = 20).

  • Percutaneous (n = 37).

• Surgical group: larger vegetations ($17.9 \pm 7$ mm vs $13.2 \pm 7$ mm, P = 0.01).

• New PM after removal: 42 patients (70%).

• Mortality factors (6 deaths – follow up $3.4 \pm 2$ years): number of vegetations and absence of device extraction (P < 0.02).

• Early onset endocarditis (within 1 year) vs late onset: no significant differences in clinical features or management.

Conclusions

• PM endocarditis: primarily staphylococcal.

• TEE: required for diagnosing vegetations.

• Complete device removal: required and associated with favorable outcomes.

Introduction

• Cardiac device implantation: life-saving but carries infection risks.

• PM infection incidence is increasing due to:

  • Increased use of ICD and cardiac resynchronization therapy.

  • Improved understanding of cardiac device infection presentation.

  • Improved survival rates leading to more