Risk factors for cardiac implantable electronic device infections: a nationwide Danish study

Abstract

Aims Cardiac implantable electronic device (CIED) infection is a severe complication to modern management of cardiac arrhythmias. The CIED type and the type of surgery are recognized as risk factors for CIED infections, but knowledge of patient-related risk factors is scarce. This study aimed to identify lifelong patient-related risk factors for CIED infections. Methods and results Consecutive Danish patients undergoing a CIED implantation or reoperation between January 1996 and April 2018 were included. The cohort consisted of 84 429 patients undergoing 108 494 CIED surgeries with a combined follow-up of 458 257 CIED-years. A total of 1556 CIED explantations were classified as either pocket (n = 1022) or systemic CIED infection (n = 534). Data were cross-linked with records from the Danish National Patient Registry and the Danish National Prescription Registry. Using multiple-record and multiple-event per subject proportional hazard analysis, specific patient-related risk factors were identified but with several variations amongst the subtypes of CIED infection. CIED reoperations were associated with the highest risk of pocket CIED infection but also CIED type, young age, and prior valvular surgery [hazard ratio (HR): 1.62, 95% confidence interval (CI): 1.29–2.04]. Severe renal insufficiency/dialysis (HR: 2.40, 95% CI: 1.65–3.49), dermatitis (HR: 2.80, 95% CI: 1.92–4.05), and prior valvular surgery (HR: 2.09, 95% CI: 1.59–2.75) were associated with the highest risk of systemic CIED infections. Congestive heart failure, ischaemic heart disease, malignancy, chronic obstructive pulmonary disease, and temporary pacing were not significant at multivariate analysis. Conclusion Specific comorbidities and surgical procedures were associated with a higher risk of CIED infections but with variations amongst pocket and systemic CIED infection. Pocket CIED infections were associated with CIED reoperations, young age and more complex type of CIED, whereas systemic CIED infections were associated with risk factors predisposing to bacteraemia.

Cardiac implantable electronic devices and bloodstream infections: management and outcomes

“…That may indicate multiple entry points, a temporary deficit of immunocompetency, or the presence of more severe comorbidities, resulting in a greater failure rate of both medical and non-pharmacological therapy. The incidence of patients diagnosed with severe BSI leading to hospitalization was around 22 per 1000 patient-years, hence considerably higher compared with the incidence rate of 2.5 per 1000 device-years after device implantation reported by Olsen et al , 32 who collected data from three nationwide registries: the Danish National Patient Registry, the Danish National Prescription Registry, and the Danish Pacemaker and ICD Register. Considering that patient characteristics at first device implant were similar between our population and the Danish study, it is reasonable to assume that around 1 out of 10 device patients admitted to a hospital with BSI will have a systemic device infection or endocarditis.…”

Low Occurrence of Infections and Death in a Real-World Cohort of Patients with Cardiac Implantable Electronic Devices

“…The low incidence of CIED-related infections may be explained by strict adherence to sterile and proper surgical techniques, antibiotic prophylaxis consistently performed in all patients and high operator experience (all cases were performed by expert electrophysiologists working in a tertiary referral center). In a recent study by Olsen et al [ 15 ], the median time to CIED infection was 296 (68–946) CIED-days, with systemic infections occurring significantly later than pocket infections. The former appeared to be associated with risk factors predisposing patients to bacteremia, while the latter was associated with surgery-related factors.…”

“…Antibiotic prophylaxis in patients potentially not represented by the previously mentioned protocol was discussed with the infectious disease specialist and tailored accordingly. An antibiotic-eluting envelope was used only in ICD/CRT patients deemed at high risk of infection according to a PADIT score > 6 [ 13 ] or dialysis [ 14 , 15 ]. The prevention of CIED infection before, during and after the implantation procedure was performed according to current guidelines/consensus documents [ 8 , 16 ].…”

Emerging optogenetics technologies in biomedical applications

“…[129][130][131] However, electronic pacemakers have been associated with several drawbacks, including electrochemical reactions at the electrode tissue interface, invasive surgery, repeated battery replacement, infection risk, and equipment failure. [132][133][134][135][136] Optogenetic technology, which involves transmitting various opsins to the heart through viral vectors and controlling heart rate through depolarization or repolarization stimulation, presents a promising alternative to electronic pacemakers. 137,138 Research has demonstrated that pacing the heart at multiple sites reduces activation time, thus leading to highly synchronized ventricular activation through the fusion of multiple wave fronts generated simultaneously by all chr2 expression sites.…”

“…In the clinical management of chronic arrhythmia and heart failure due to different ventricular pacings, the electronic pacemaker has been the predominant treatment 129–131 . However, electronic pacemakers have been associated with several drawbacks, including electrochemical reactions at the electrode tissue interface, invasive surgery, repeated battery replacement, infection risk, and equipment failure 132–136 . Optogenetic technology, which involves transmitting various opsins to the heart through viral vectors and controlling heart rate through depolarization or repolarization stimulation, presents a promising alternative to electronic pacemakers 137,138 .…”