Yasser Rodriguez

Management of cardiac device-related infections: A review of protocol-driven care

BACKGROUND The prevalence of cardiac device-related infections (CDIs) has mirrored the unprecedented increase in device usage. CDIs are currently one of the leading indications for extraction. Despite this, there is limited data regarding the clinical trends, management and outcomes associated with this complication. METHODS A review of a prospective registry of all patients undergoing device extraction between January 1, 2004, and June 15, 2009, at a single high-volume tertiary referral center was performed. RESULTS A total of 506 consecutive patients were identified. From these, 350 patients were identified as having a CDI (205 ICD, 145 PPM). The mean age was 69.9 ± 13.7. Although most patients presented clinically with signs of a pocket infection (PI) (42%), the most common final diagnosis was cardiac device infective endocarditis (CDIE) (57%). The two most common pathogens were methicillin-resistant Staphylococcus aureus (27%) and methicillin-resistant Staphylococcus epidermidis (23%); they accounted for 69% of all deaths. Cultures taken from pocket tissue as opposed to exudates displayed higher concordance with lead-tip cultures (56% and 31% respectively). The mean time from explantation to device reimplantation for PIs, bacteremia and CDIE was 6.7 ± 4.7, 10.25 ± 4.7 and 11.39 ± 16.6 days respectively. CONCLUSION CDIs are a serious complication associated with device usage. Diagnosis and management protocols for CDIs should feature transesophageal echocardiography; complete hardware extraction; broad-spectrum antibiotics that cover methicillin-resistant Staphylococci and cultures derived from lead-tips and preferably pocket tissue. Immediate device reimplantation is possible in noninfectious cases; several factors should be considered regarding reimplantation in cases involving CDIs.

Management of symptomatic inadvertently placed endocardial leads in the left ventricle.

Background: There are limited data regarding the clinical care of inadvertently placed endocardial leads in the left ventricle (LV). We clarified the appropriate management within the context of our experience and published literature.

Laser Lead Extraction in the Octogenarian Patient

Background— In the United States, patients aged >75 years are the most rapidly growing segment in the population, with an expected increase of 126% by 2050. These patients account for >70% of the pacemakers and up to two thirds of the implantable cardioverter-defibrillators implanted annually. Our aim was to explore the clinical outcomes of device complications in the octogenarian population. Methods and Results— We performed a retrospective chart review of 506 patients undergoing laser lead extraction from January 2004 to September 2009. This population was divided into the following 2 groups based solely on age: octogenarians and nonoctogenarians. These 2 groups were compared on the basis of several characteristics and clinical outcomes. There were 118 patients in the octogenarian group (78 men) and 388 in the nonoctogenarians group (301 men) aged 85±3.8 and 64.2±12.4 years, respectively. A total of 253 leads (atrial, 99; ventricular, 145; coronary sinus, 9) were removed from the patients in the octogenarian group, and 814 leads (atrial, 295; ventricular, 442; coronary sinus, 77) were removed from the patients in the nonoctogenarian group. The main indication for extraction for both groups was infection. The lead implant duration was 59.6±52.8 and 38.6±43.9 months for octogenarians and nonoctogenarians, respectively. There was no significant difference with respect to the proportion of minor (P=0.65), major (P=0.56), and total (P=0.50) complications. Conclusions— Laser lead extraction is demonstrated to be a safe and effective treatment method in octogenarian patients with multiple comorbidities.

Cardiac Device‐Related Endocarditis Complicated by Spinal Abscess

Background: Infective endocarditis is the most serious manifestation of cardiac device infection and metastatic seeding of distant sites has been reported. However, the association between device‐related endocarditis and spinal abscess has not been fully described.

A Novel Retrograde Laser Extraction Technique Using a Transatrial Approach: An Alternative for Complex Lead Extractions

Background— The use of percutaneous lead extraction techniques in a patient with extracardiac or protruding atrial leads could have disastrous consequences. Traditionally, the management of these patients has included a median sternotomy. We describe a minimally invasive technique that involves a transatrial, retrograde laser lead extraction using a video-assisted thoracoscopic approach. Methods and Results— Between January 2004 and June 2009, 14 patients with severed leads at the clavicle and extracardiac leads or lead-caused erosions of the atrial wall were identified through chest radiograph and CT scan. There were 9 men and 5 women aged 19 to 91 years (mean age, 69.71±20.67 years). Ten devices were pacemakers, and 4 were defibrillators. Indications for extraction were 12 infections and 2 malfunctions. Mean ejection fraction was 42±17.67% (range, 10% to 65%). Time of implanted leads was 93.69±51.88 months (range, 33 to 213 months). Laser sheaths size were 12 F (7.1%), 14 F (85.7%), and 16 F (7.1%). A right-side thoracoscopy was performed under general anesthesia. A retrograde laser sheath maneuver was performed, freeing the lead from any adhesions. The lead was removed and the incision closed. One patient experienced a pleural effusion. There was no mortality, and all patients were alive and well at 1-month follow-up. Conclusions— Transatrial, retrograde laser lead extraction is a safe and effective procedure. This procedure may provide an excellent alternative to open sternotomy.

Aortic balloon valvuloplasty in pregnancy for symptomatic severe aortic stenosis.

During pregnancy, several profound changes occur in the cardiovascular system including a significant increase in cardiac output. The presence of valvular heart disease during pregnancy further perturbs these complex hemodynamics. A severe, fixed stenosis, whether aortic stenosis (AS) or mitral stenosis (MS) may drastically impede forward flow and prevent further increases in cardiac output, in turn leading to symptoms of dyspnea, congestive heart failure, pulmonary edema, shock, and possibly death. Thus, pregnant womenwith stenotic valvular pathology represent a unique, challenging group of patients that are at an increased risk for adverse outcomes. In older series, pregnancy in women with congenital AS was associated with increased maternal mortality rates, ranging from 11 to 20% [1,2]. In more recent series involving pregnant women with congenital AS, the mortality and cardiac event rates were lower with approximately 10% of patients suffering a cardiac event; these events consisted primarily of congestive heart failure or atrial arrhythmias [3,4]. We present two cases of patients with symptomatic, severe AS that were successfully treated toward the end of the second trimester with balloon aortic valvuloplasty (BAV). The procedures were performed in order to provide symptomatic relief, as well as bridge the patients through their pregnancies. Fetal heart rate monitoring was used throughout the procedure; there were adverse effects noted during the procedure or at two-year follow up. Thefirst patientwas a 43 year old pregnantmotherwho immigrated to the United States 18 years prior. Past medical history was significant

Ankle-brachial Index as a Clinical Tool

A 62-year-old woman with a medical history of smoking, hypertension, osteoarthritis, and diabetes presents to her primary care physician for evaluation of leg pain. She reports lower-extremity discomfort and fatigue that is exertional in nature but does not consistently resolve on rest. Physical examination reveals a blood pressure of 151/85 mm Hg, pulse rate of 75 beats/min, weak and thready popliteal pulses and posterior tibial pulses, and mild tenderness to palpation of her hips but no musculoskeletal weakness. There is a normal pattern of hair growth on her shins bilaterally with areas of light brown scaly patches throughout. Cardiopulmonary examination reveals clear lungs to auscultation bilaterally with good effort, a normal s1/s2 with no murmurs or gallops, and a laterally displaced point of maximal impulse. What tests can help in the evaluation of this patient’s leg pain?

Conservative management of an elderly patient with Eisenmenger syndrome

Background Eisenmenger syndrome (ES) in the adult population has become exceedingly rare in developed countries owing to better recognition and treatment of congenital malformations of the heart. In the absence of transplantation, most patients survive an average of 20-30 years before succumbing to the cardiovascular and hemostatic sequelae. We present a rare case of an elderly woman with ES secondary to an uncorrected atrial-septum defect. She continues to have a high functional capacity despite impressive hemodynamic parameters. Case A 69-year-old woman with ES presented to our facility with atrial fibrillation and volume overload. She has a known sinus venosus atrial septal defect and associated severe pulmonary hypertension. She was managed conservatively and discharged on bosentan given her intricate physiology. Conclusion Given the similarity of the pathology with idiopathic pulmonary arterial hypertension (IPAH) and ES, drugs that are usually reserved for IPAH such as prostanoids and phosphodiesterase type 5 inhibitors may be beneficial in the management of ES. This case highlights that with our improving understanding of ES, non-operative management may have an expanding role in the care of these complex patients.<Learning objective: Advanced therapy for Eisenmenger syndrome (ES) is geared toward the endothelin-1 mediated pulmonary arterial plexus. Given the similarity of the pathology with idiopathic pulmonary arterial hypertension (IPAH) and ES, drugs that are usually reserved for IPAH such as prostanoids and phosphodiesterase type 5 inhibitors may be beneficial in the management of ES. Conservative management can achieve a favorable outcome, even in elderly patients with advanced disease.>.

Systemic amyloidosis presenting as constrictive pericarditis in a young adult

Pericardial amyloidosis without myocardial involvement is a rare event, even rarer when it affects an individual in their second decade of life [1]. In general, systemic amyloidosis (SA) refers to a group of disease processes involving abnormal protein deposition that usually affects individuals in the sixth decade of life [2]. When there is cardiac involvement, the typical presentation is that of a right-sided heart failure due to a restrictive cardiomyopathy, with infiltration of the myocardium by amyloid protein. Pericardial involvement, when present, is mostly an extension of the myocardial process [1]. We present an exceptionally rare case of SA presenting as congestive heart failure due to pericardial amyloidosis without gross myocardial involvement in a 21-year-old male. Although both constrictive pericarditis and restrictive cardiomyopathy have similar clinical presentations, timely differentiation is necessary since both conditions require different therapeutic approaches [3]. A 21-year-old Caucasian male presented to our center in 6/2010 due to generalized swelling associated with fatigue, malaise and shortness of breath. The patient had a past medical history of recurrent pneumonia associated with pleural effusions for the past two years, beginning in 7/2008. During the past two years, every time the patient had an episode of pneumonia and shortness of breath, he would go to a regional hospital where his pleural effusion would be drained, providing symptomatic relief. During this time period, there was a limited effort to identify the etiology of his recurrent pneumonia. In 4/2010, the patient was diagnosed with an empyema, prompting a thoracoscopy and lung decortication. In 6/2010, his symptoms recurred and this time the patient presented to our facility. On physical examination, pallor was present and his vital signs showedmild tachycardia and pronounced tachypnea. On auscultation, breath sounds were decreased bilaterally in both basilar regions. There was no wheezing present, but mild rales were appreciated throughout both lung fields. Pitting edema involving the lower limbs, sacral region and abdominal wall was observed as well. Initial labs demonstrated profound hypoalbuminemia, evaluation by nephrology ruled out renal origin. Gastroenterology was consulted, and a colonoscopy, esophagogastroduodenoscopy (EGD) and biopsies of the liver and intestines were performed. The colonoscopy and EGD revealed grossly normal appearing mucosa; however, the biopsies were positive using Congo red stain. The samples demonstrated sinusoidal apple green birefringency under polarized light, consistent with amyloidosis. Chest CT scan demonstrated several enlarged lymph nodes; this finding prompted a workup by oncology. Lymphoma was ruled out after flow cytometry and other hematologic studies tested normal. Further workup included a venogram and a trans-abdominal ultrasound of the inferior vena cava and hepatic veins, which showed marked venous dilation (Fig. 1). Cardiac catheterization demonstrated ventricular interdependence and equalization of end diastolic pressures throughout the cardiac chambers with less than 5 mm Hg variation, suggesting the possibility of constrictive pericarditis. In addition to those findings, there was significant elevation of the right atrial pressure, with an elevated backpressure gradient in the jugular veins, inferior vena cava and hepatic veins. CT chest angiography showed marked, loculated right pleural thickening and a free left pleural effusion associated with basal lobe atelectasis. The heart was at the upper limit of normal in size and only slight pericardial thickening, measuring approximately 4.8 mm, was appreciated in the anterior side. Electrocardiography did not show microvoltage or any sign of myocardial involvement. He was empirically started on IV furosemide and potassium chloride with little clinical improvement. Doppler echocardiography showed that both ventricles were normal in size, along with a normal left ventricular wall thickness and an ejection fraction of 55–60%. The inferior vena cava was severely dilated with no inspiratory collapse. The study also demonstrated a small pericardial effusion and a large left pleural effusion. AnMRI of the heart (Fig. 2) showed normal biventricular function in the presence of several findings related to the pericardium. The study demonstrated borderline thickening of the pericardium, pericardial enhancement, tubular appearance of the ventricles and increased ventricular interdependence, suggestive of pericardial constriction. On the basis of clinical judgment coupled with the results of the patients workup, the patient underwent a median sternotomy and International Journal of Cardiology 153 (2011) e7–e9

Racial and ethnic healthcare disparities in patients undergoing laser lead extraction

BACKGROUND The rate of cardiovascular implantable electronic device infections (CIEDIs) has mirrored or exceeded the increased use of implantable cardiac devices in the United States. The presence of racial and ethnic disparities associated with CIEDIs has not been published. Our aim is to describe the presence of racial and ethnic disparities with respect to the management of CIEDIs. METHODS We reviewed a prospective single-center registry for patients undergoing removal of an implantable cardiac device between 1/2004 and 1/2016. 1173 consecutive patients underwent device extraction. 699 patients were identified as having an infection, 305 were identified as Caucasian and 394 were minorities (91 African Americans, 303 Hispanics). Patients had pre-operative transesophageal echocardiograms (TEEs) and collection of blood and exudate cultures. All underwent complete hardware extraction; leads were removed through the use of locking stylets and traction or laser extraction. En-bloc capsulectomy was performed with intraoperative specimen collection from pocket tissue, exudate, lead tips, and vegetations. RESULTS Minority patients were: younger (67.9 ± 14.5 years vs 72.4 ± 13.2 years), had a higher proportion of male gender, diabetes, and chronic renal failure (p < 0.001). Minorities experienced a higher rate of complications during extraction and a longer hospitalization (15.3 ± 9.9 days versus 17.4 ± 13.4 days, p < 0.001). There was no significant difference between the proportion of types of infection in both groups. CONCLUSION Minority patients with CIEDIs experienced more procedural complications during extraction and had a significantly longer length of index hospitalization than Caucasian patients.