Author + information
- ↵⁎Reprint requests and correspondence:
Dr. James D. Maloney, Carondelet Heart Institute, Cardiology, 1000 Carondelet Drive, Kansas City, Missouri 64114
The descriptive analysis in this issue of the Journalby Grammes et al. (1) of their percutaneous rhythm device-lead extraction experience in 100 infective endocarditis patients with 216 leads (average lead age 4 years) and further complicated by large intracardiac vegetations is admirable, instructive, and thought provoking. The data primarily come from prospectively maintained lead extraction records, plus retrospective assessment of the pre- and post-extraction course during a 16-year time frame.
All 100 patients and their infected leads were complicated by intra-cardiac vegetations ranging in size from 0.2 to 4.0 cm (mean 1.6 cm), all fulfilling the modified Duke criteria (2) for possible or definite rhythm device-related infective endocarditis. The principle management team included the pacemaker electrophysiology extraction members, anesthesiologists, and infectious disease consultants, and cardiac surgeons only when new epicardial lead systems were required in 2 patients. Throughout the 16 years of this retrospective analysis, a generally consistent therapeutic approach was followed by this center that included local and tertiary referral patients. The authors' lead extraction approach included the following: 1) attempted identification of the infecting organism with cultures; 2) pre-procedure esophageal echo imaging (transesophageal echocardiography) for identification of vegetations from in-house or referral sources, plus localizing and sizing of right-sided heart vegetations; 3) infectious disease service management of antibiotics to suppress bacteremia; 4) extraction of all implanted pulse generators and intravascular leads using percutaneous extraction tools and techniques of the day, regardless of vegetation size or location; 5) post-lead extraction/transvenous pacing, antibiotics, medical treatment of progressive heart failure and overwhelming sepsis, plus subsequent reimplantation of new, usually transvenous, implanted pulse generator–lead systems when appropriate.
The authors noted that extraction times were equal to (or shorter for infected leads) lead extraction times for 2,004 noninfected leads. We believe this is a valid observation, but rarely documented in print or timed, and is assumed to be due to localized bacterial breakdown of fibrosis and tissue adjacent to the lead, and not necessarily related to vegetation.
Size of the vegetations did not alter the authors' pre-procedure evaluation, extraction techniques, and timing, nor did they find that vegetations have a significant effect on acute procedure mortality. Two patients did have acute pulmonary and hemodynamic symptoms attributed to vegetation embolus; both stabilized in a few hours. Hospital mortality and 30-day mortality totaled 10 patients (10%), and no deaths were directly related to a pulmonary vegetation embolus; however, most deaths were attributed to progressive heart failure and overwhelming sepsis. One patient did have procedure-related severe traumatic tricuspid insufficiency. Late mortality was 19%, although some patients were lost to follow-up.
The authors' procedural success with percutaneous lead extraction for patients with infective endocarditis (IE) and large vegetations is encouraging and adds significantly to existing reports advocating percutaneous removal (3–6). These data support the growing belief that right-sided heart vegetations <3 or 4 cm (or regardless of size) are not a contraindication to percutaneous lead extraction. However, there are dissenters, especially from the cardiac surgical community, who vigorously contend that rhythm device-related IE with large vegetations should be managed with surgical removal including debridement despite significant morbidity and mortality. Unfortunately, randomized trials do not exist regarding this issue and are unlikely to be performed any time in the near future. Our review of the IE literature identifies left-sided heart vegetation as a major risk marker, and subsequent embolization as a life-threatening event complicating 20% to 50% of left-sided heart IE cases (7–9). This is particularly true when vegetations are >10 mm and have increasing proclivity to embolize. Current literature review suggests the 3 major indications for surgical management of left-sided IE are: 1) new onset or progressive heart failure; 2) uncontrolled infection; and 3) prevention of embolic vegetation (9,10). Rarely do vegetations exist alone. Left-sided surgical intervention is directed toward removing the vegetations, while also correcting for causes of congestive heart failure (valve repair), along with debriding and draining infectious sources that are resistant to antibiotic penetration (11). Isolated surgical removal of left heart vegetation does not reduce mortality (11–13).
It seems that criteria for left-sided heart IE and direct surgical interventions is, in part, being transferred to right-side heart vegetations without considering all of the nuances. Most of these patients are very sick: right- or left-sided heart IE complicated by large vegetations. All would agree that right-sided heart IE with large vegetations is not good, but the data of Grammes et al. (1), and those of others (3,4,10), suggest that even large embolic right-sided heart vegetations can be withstood by most patients if coexisting endocarditis is suppressed and eventually cured in the setting of successful total device and lead extraction. The Grammes data also identify a number of patients with successfully extracted hardware and large vegetations who progressed to a state of intractable congestive heart failure and/or uncontrolled and overwhelming sepsis despite appropriate medical treatment. Apparently, the vegetations of these patients disappeared with extraction, but the remaining right-sided heart environment is unknown. Mortality from uncontrolled sepsis, with and without heart failure despite appropriate antibiotics, could, in part, be due to residual infected inflammatory tissue, possibly within the right heart, lung, or implant pocket, or related to the temporary pacing leads, even with prior total hardware extraction (14–17). If we agree that extensive debridement of pectoral pockets and aortic perivalvular abscesses is important, then the potential value of right-sided heart debridement in refractory rhythm device IE (after lead removal), should be further considered, studied, and defined.
A simple investigative approach would be to perform autopsies on patients with device-related endocarditis who succumbed to uncontrolled sepsis despite total transvenous hardware extraction. A residual abscessed tissue-scar complex that promotes embolized vegetation is also possibly seeding the rest of the body and contributing to refractoriness of infection and congestive failure. Another investigational tool is delayed-enhancement magnetic resonance imaging (18,19) of post-extraction patients with continued sepsis in an attempt to identify specific sites of right-sided heart inflammatory tissue impervious to antibiotic therapy. If found, imaging could guide surgeons or electrophysiologists toward targeted intracardiac debridement.
Grammes et al. (1) are to be congratulated for their acutely successful transvenous lead extraction experience in the presence of large right-sided heart vegetations. The results, both short and long term, can help formulate additional questions and treatment strategies to deal with the presence or absence of possible residual inflammatory tissue with and without vegetations. Grammes et al. (1) demonstrate that percutaneous lead extraction with vegetations of all sizes is possible and seemingly appropriate. Techniques to collect or suction the vegetation before embolizing could be developed, and may be helpful. The question remains, however, if a nidus of chronic infection sometimes remains, does that cause refractory sepsis and congestive heart failure? Can and should it be removed surgically?
Although not directly related to intracardiac vegetations, the question of silent bacterial spread of device-pocket infection to the heart needs more investigation. Is it possible that the open lumen of the typical lead permits bacteria to hide from antibiotics within the fluid-filled connecter block? Then can it silently travel to the endocardial tip to repetitively initiate bursts of bacteremia and endocarditis, thereby enabling drainage from a relatively normal looking pectoral pocket? Would a lead without a lumen help solve this problem? Is this a problem? A team approach of device-extraction specialists along with infectious disease physicians, cardiac surgeons, imaging experts, pathologists, device manufacturers, and others may best solve these clinical puzzles. Similarly, once endocarditis becomes refractory to medical therapy despite percutaneous hardware extraction, can directed surgical intervention improve patient outcomes?
As one glances back to the time of emerging open heart surgery, iatrogenic heart block, and the first battery-powered pacemakers, specialists of every type came together as one large community to solve common problems. Today, we are building compartmentalized units of medicine, or “silos” (20), that are becoming smaller and smaller. The upward thrust of the silo is often impressive and rapid, but isolated. For example, cardiac electrophysiology is a silo of subspecialty practice derived in part from cardiology, internal medicine, and surgery. Cardiac electrophysiology is now making smaller silos consisting of noninvasive, invasive, and interventional physicians, plus heart failure specialists implanting biventricular devices, interventional atrial fibrillation ablation specialists, ventricular tachycardia ablation specialists, device follow-up specialists, lead extraction specialists, and others. The unintended consequences of too narrow a focus, or too small a silo, may delay and geographically or departmentally disperse care, and that could end up being counter to a patient-centered health care delivery system.
It seems that in future investigations of this type, the shaping, evaluating, and drawing of meaningful conclusions might benefit from the knowledge and experience of multiple specialties, both medical and surgical. The broader perspective rather than a narrow silo framework may result in more clinically significant observations. In the present study, IE and its sequelae, vegetations, generate other unanswered questions: Why do some patients get better with extractions and others do not? Are vegetations and vegetation size only markers of underlying infection?
There appears to be a need to explore these questions through a broader framework for more comprehensive understanding. The excellent work by Grammes et al. (1) needs to be continued.
↵⁎ Editorials published in the Journal of the American College of Cardiologyreflect the views of the authors and do not necessarily represent the views of JACCor the American College of Cardiology.
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