Skip to main content

Advertisement

Log in

Cardiovascular Implantable Device Infections

  • Published:
Current Infectious Disease Reports Aims and scope Submit manuscript

Abstract

As life expectancy continues to increase and biotechnology advances, the use of cardiovascular implantable devices will continue to rise. Unfortunately, despite modern medical advances, the infection and mortality rates remain excessively elevated. This article reviews the pathophysiology and general concepts of cardiac device–related infections, including the physical and chemical characteristics of the medical device, host response to the medical device, and the microbiologic virulence factors. Infections of the most commonly utilized cardiovascular implantable devices, including cardiovascular implantable electronic devices, bioprosthetic and mechanical valves, ventricular assist devices, total artificial hearts, and coronary artery stents, are reviewed in detail.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Cabell CH, Heidenreich PA, Chu VH, et al. Increasing rates of cardiac device infections among Medicare beneficiaries: 1990–1999. Am Heart J. 2004;47:582–6.

    Article  Google Scholar 

  2. Monkowski DH, Axelrod P, Fekete T, et al. Infections associated with ventricular assist devices: epidemiology and effect on prognosis after transplantation. Transpl Infect Dis. 2007;9:114–20.

    Article  PubMed  CAS  Google Scholar 

  3. Darouiche RO. Treatment of infections associated with surgical implants. N Engl J Med. 2004;350:1422–9.

    Article  PubMed  CAS  Google Scholar 

  4. Darouiche RO. Device-associated infections: a macroproblem that starts with microadherence. Clin Infect Dis. 2001;33:1567–72.

    Article  PubMed  CAS  Google Scholar 

  5. Phaller MA, Herwaldt LA. Laboratory, clinical, and epidemiological aspects of coagulase-negative staphylococci. Clin Microbiol Rev. 1988;1:281–99.

    Google Scholar 

  6. •• Baddour LM, Epstein AE, Erickson CC, et al. Update on cardiovascular implantable electronic device infections and their management: a scientific statement from the American Heart Association. Circulation. 2010;121:458–77. The most up-to-date guideline of infections of cardiovascular implantable electronic devices..

    Article  PubMed  Google Scholar 

  7. Baddour LM, Bettmann MA, Bolger AF, et al. Nonvalvular cardiovascular device-related infections. Circulation. 2003;108:2015–31.

    Article  PubMed  Google Scholar 

  8. Kreutzer J, Ryan CA, Gauvreau K, et al. Healing response to the Clamshell device for closure of intracardiac defects in humans. Catheter Cardiovasc Interv. 2001;54:101–11.

    Article  PubMed  CAS  Google Scholar 

  9. Lin K, Hsu PP, Chen BP, et al. Molecular mechanism of endothelial growth arrest by laminar shear stress. Proc Natl Acad Sci USA. 2000;97:9385–9.

    Article  PubMed  CAS  Google Scholar 

  10. Fisher AB, Chien S, Barakat AI, et al. Endothelial cellular response to altered shear stress. Am J Physiol Lung Cell Mol Physiol. 2001;281:L529–33.

    PubMed  CAS  Google Scholar 

  11. Shive MS, Hasan SM, Anderson JM. Shear stress effects on bacterial adhesion, leukocyte adhesion, and leukocyte oxidative capacity on a polyetheurethane. J Biomed Mater Res. 1999;46:511–9.

    Article  PubMed  CAS  Google Scholar 

  12. Ankersmit HJ, Tugulea S, Spanier T, et al. Activation-induced T-cell death and immune dysfunction after implantation of left-ventricular assist device. Lancet. 1999;354:550–5.

    Article  PubMed  CAS  Google Scholar 

  13. Heilmann C, Schweitzer O, Gerke C, et al. Molecular basis of intercellular adhesion in the biofilm-forming Staphylococcus epidermidis. Mol Microbiol. 1996;20:1083–91.

    Article  PubMed  CAS  Google Scholar 

  14. Francois P, Vaudaux P, Lew PD. Role of plasma and extracellular matrix proteins in the pathophysiology of foreign body infections. Ann Vasc Surg. 1998;12:34–40.

    Article  PubMed  CAS  Google Scholar 

  15. Vuong C, Otto M. Staphylococcus epidermidis infections. Microbes Infect. 2002;4:481–9.

    Article  PubMed  Google Scholar 

  16. •• Voigt A, Shalaby A, Saba S. Continued rise in rates of cardiovascular implantable electronic device infections in the United States: temporal trends and causative insights. Pacing Clin Electrophysiol. 2010;33:414–9. The authors clearly articulate the disproportional increase in the number of infections of cardiovascular implantable electronic devices, as compared with the rising implantation rate of these devices.

    Article  PubMed  Google Scholar 

  17. Sohail MR, Uslan DZ, Khan AH, et al. Management and outcome of permanent pacemaker and implantable cardioverter-defibrillator infections. J Am Coll Cardiol. 2007;49:1851–9.

    Article  PubMed  Google Scholar 

  18. Conklin EF, Giannelli Jr S, Nealon Jr TF. Four hundred consecutive patients with permanent transvenous pacemakers. J Thorac Cardiovasc Surg. 1975;69:1–7.

    PubMed  CAS  Google Scholar 

  19. Lai KK, Fontecchio SA. Infections associated with implantable cardioverter defibrillators placed transvenously and via thoracotomies: epidemiology, infection control, and management. Clin Infect Dis. 1998;27:265–9.

    Article  PubMed  CAS  Google Scholar 

  20. Ferguson Jr TB, Ferguson CL, Crites K, Crimmins-Reda P. The additional hospital costs generated in the management of complications of pacemaker and defibrillator implantations. J Thorac Cardiovasc Surg. 1996;111:742–52.

    Article  PubMed  Google Scholar 

  21. Bloom H, Heeke B, Leon A, et al. Renal insufficiency and the risk of infection from pacemaker or defibrillator surgery. Pacing Clin Electrophysiol. 2006;29:142–5.

    Article  PubMed  Google Scholar 

  22. Baman TS, Gupta SK, Valle JA, Yamada E. Risk factors for mortality in patients with cardiac device-related infection. Circ Arrhythm Electrophysiol. 2009;2:129–34.

    Article  PubMed  Google Scholar 

  23. Sohail MR, Uslan DZ, Khan AH, et al. Risk factor analysis of permanent pacemaker infection. Clin Infect Dis. 2007;45:166–73.

    Article  PubMed  Google Scholar 

  24. Klug D, Balde M, Pavin D, et al. Risk factors related to infections of implanted pacemakers and cardioverter-defibrillators: results of a large prospective study. Circulation. 2007;116:1349–55.

    Article  PubMed  Google Scholar 

  25. Mela T, McGovern BA, Garan H, et al. Long-term infection rates associated with the pectoral versus abdominal approach to cardioverter-defibrillator implants. Am J Cardiol. 2001;88:750–3.

    Article  PubMed  CAS  Google Scholar 

  26. Gil P, Fernández Guerrero ML, Bayona JF, et al. Infections of implantable cardioverterdefibrillators: frequency, predisposing factors and clinical significance. Clin Microbiol Infect. 2006;12:533–7.

    Article  PubMed  CAS  Google Scholar 

  27. Johansen C, Feychting M, Møller M, et al. Risk of severe cardiac arrhythmia in male utility workers: a nationwide danish cohort study. Am J Epidemiol. 2002;156:857–61.

    Article  PubMed  Google Scholar 

  28. Al-Khatib SM, Lucas FL, Jollis JG, et al. The relation between patients’ outcomes and the volume of cardioverter-defibrillator implantation procedures performed by physicians treating Medicare beneficiaries. J Am Coll Cardiol. 2005;46:1536–40.

    Article  PubMed  Google Scholar 

  29. Chamis AL, Peterson GE, Cabell CH, et al. Staphylococcus aureus bacteremia in patients with permanent pacemakers or implantable cardioverter-defibrillators. Circulation. 2001;104:1029–33.

    Article  PubMed  CAS  Google Scholar 

  30. • Viola GM, Awan LL, Darouiche RO. Nonstaphylococcal infections of cardiac implantable electronic devices. Circulation. 2010;121:2085–91. The authors describe the characteristics of 80 individuals with nonstaphylococcal infection of cardiac implantable electronic devices..

    Article  PubMed  Google Scholar 

  31. •• de Oliveira JC, Martinelli M, Nishioka SA, et al. Efficacy of antibiotic prophylaxis before the implantation of pacemakers and cardioverter-defibrillators: results of a large, prospective, randomized, double-blinded, placebo-controlled trial. Circ Arrhythm Electrophysiol. 2009;2:29–34. This double-blinded randomized controlled study clearly demonstrated that perioperative antibiotics reduce the rate of infections of cardiac implantable electronic devices..

    Article  PubMed  Google Scholar 

  32. Klug D, Lacroix D, Savoye C, et al. Systemic infection related to endocarditis on pacemaker leads: clinical presentation and management. Circulation. 1997;95:2098–107.

    PubMed  CAS  Google Scholar 

  33. Chambers ST. Diagnosis and management of staphylococcal infections of pacemakers and cardiac defibrillators. Intern Med J. 2005;35:S63–71.

    Article  PubMed  Google Scholar 

  34. • Rohacek M, Weisser M, Kobza R, et al. Bacterial colonization and infection of electrophysiological cardiac devices detected with sonication and swab culture. Circulation. 2010;121:1691–7. This study showed that approximately one-third of individuals with an explanted cardiac implantable electronic device without any sign for infection are asymptomatically bacterially colonized..

    Article  PubMed  Google Scholar 

  35. Mason PK, Dimarco JP, Ferguson JD, et al.: Sonication of explanted cardiac rhythm management devices for the diagnosis of pocket infections and asymptomatic bacterial colonization. Pacing Clin Electrophysiol. Published ahead of print on June 17, 2010.

  36. Chua JD, Wilkoff BL, Lee I, et al. Diagnosis and management of infections involving implantable electrophysiologic cardiac devices. Ann Intern Med. 2000;133:604–8.

    PubMed  CAS  Google Scholar 

  37. Giamarellou H. Nosocomial cardiac infections. J Hosp Infect. 2002;50:91–105.

    Article  PubMed  CAS  Google Scholar 

  38. Cacoub P, Leprince P, Nataf P, et al. Pacemaker infective endocarditis. Am J Cardiol. 1998;82:480–4.

    Article  PubMed  CAS  Google Scholar 

  39. Catanchin A, Murdock CJ, Athan E. Pacemaker infections: a 10-year experience. Heart Lung Circ. 2007;16:434–9.

    Article  PubMed  Google Scholar 

  40. Meier-Ewert HK, Gray ME, John RM. Endocardial pacemaker or defibrillator leads with infected vegetations: a single-center experience and consequences of transvenous extraction. Am Heart J. 2003;146:339–44.

    Article  PubMed  Google Scholar 

  41. • Grammes JA, Schulze CM, Al-Bataineh M, et al. Percutaneous pacemaker and implantable cardioverter-defibrillator lead extraction in 100 patients with intracardiac vegetations defined by transesophageal echocardiogram. J Am Coll Cardiol. 2010;55:886–94. The authors described the feasibility, safety, and clinical outcomes of percutaneous lead extraction in patients who had intracardiac vegetations identified by transesophageal echocardiogram..

    Article  PubMed  Google Scholar 

  42. Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med. 2004;351:1645–54.

    Article  PubMed  CAS  Google Scholar 

  43. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007;116:1736–54.

    Article  PubMed  Google Scholar 

  44. Wang A, Athan E, Pappas PA, et al. Contemporary clinical profile and outcome of prosthetic valve endocarditis. JAMA. 2007;297:1354–61.

    Article  PubMed  CAS  Google Scholar 

  45. Vongpatanasin W, Hillis LD, Lange RA. Prosthetic heart valves. N Engl J Med. 1996;335:407–16.

    Article  PubMed  CAS  Google Scholar 

  46. Wilson WR, Jaumin PM, Danielson GK, et al. Prosthetic valve endocarditis. Ann Intern Med. 1975;82:751–6.

    PubMed  CAS  Google Scholar 

  47. Fariñas MC, Pérez-Vázquez A, Fariñas-Alvarez C, et al. Risk factors of prosthetic valve endocarditis: a case-control study. Ann Thorac Surg. 2006;81:1284–90.

    Article  PubMed  Google Scholar 

  48. Calderwood SB, Swinski LA, Waternaux CM, et al. Risk factors for the development of prosthetic valve endocarditis. Circulation. 1985;72:31–7.

    Article  PubMed  CAS  Google Scholar 

  49. Hyde JA, Darouiche RO, Costerton JW. Strategies for prophylaxis against prosthetic valve endocarditis: a review article. J Heart Valve Dis. 1998;7:316–26.

    PubMed  CAS  Google Scholar 

  50. Knoll BM, Baddour LM, Wilson WR. Prosthetic valve endocarditis. In: Mandell GL, editor. Principles and practice of infectious diseases. 7th ed. Philadelphia: Churchill Livingstone; 2004. p. 1113–26.

    Google Scholar 

  51. Li JS, Sexton DJ, Mick N, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis. 2000;30:633–8.

    Article  PubMed  CAS  Google Scholar 

  52. Lepidi H, Casalta JP, Gouriet F, et al. Infective endocarditis incidentally discovered by pathological examination. J Clin Pathol. 2008;61:233–4.

    Article  PubMed  CAS  Google Scholar 

  53. Hanai M, Hashimoto K, Mashiko K, et al. Active infective endocarditis: management and risk analysis of hospital death from 24 years’ experience. Circ J. 2008;72:2062–8.

    Article  PubMed  Google Scholar 

  54. McFarland MM. Pathology of infective endocarditis. In: Kaye D, editor. Infective endocarditis. New York: Raven; 1992. p. 57–83.

    Google Scholar 

  55. Zussa C, Galloni MR, Zattera GF, et al. Endocarditis in patients with bioprosthesis: pathology and clinical correlations. Int J Cardiol. 1984;6:719–35.

    Article  PubMed  CAS  Google Scholar 

  56. Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. Circulation. 2005;111:e394–434.

    Article  PubMed  Google Scholar 

  57. Habib G, Tribouilloy C, Thuny F, et al. Prosthetic valve endocarditis: who needs surgery? A multicentre study of 104 cases. Heart. 2005;91:954–9.

    Article  PubMed  CAS  Google Scholar 

  58. Tugtekin S, Matschke K, Daubner D, et al. Prosthetic valve endocarditis: importance of surgical treatment. Thorac Cardiovasc Surg. 2007;55:94–8.

    Article  PubMed  CAS  Google Scholar 

  59. López J, Revilla A, Vilacosta I, et al. Definition, clinical profile, microbiological spectrum, and prognostic factors of early-onset prosthetic valve endocarditis. Eur Heart J. 2007;28:760–5.

    Article  PubMed  Google Scholar 

  60. Baddley JW, Benjamin Jr DK, Patel M, et al. Candida infective endocarditis. Eur J Clin Microbiol Infect Dis. 2008;27:519–29.

    Article  PubMed  CAS  Google Scholar 

  61. Anderson DJ, Olaison L, McDonald JR, et al. Enterococcal prosthetic valve infective endocarditis: report of 45 episodes from the International Collaboration on Endocarditis-merged database. Eur J Clin Microbiol Infect Dis. 2005;24:665–70.

    Article  PubMed  CAS  Google Scholar 

  62. Tang DG, Oyer PE, Mallidi HR. Ventricular assist devices: history, patient selection, and timing of therapy. J Cardiovasc Transl Res. 2009;2:159–67.

    Article  PubMed  Google Scholar 

  63. Schulman AR, Martens TP, Christos PJ, et al. Comparisons of infection complications between continuous flow and pulsatile flow left ventricular assist devices. J Thorac Cardiovasc Surg. 2007;133:841–2.

    Article  PubMed  Google Scholar 

  64. • Topkara VK, Kondareddy S, Malik F, et al. Infectious complications in patients with left ventricular assist device: etiology and outcomes in the continuous-flow era. Ann Thorac Surg. 2010;90:1270–7. The authors perform a detailed description of 42 patients with infection of the new-generation continuous-flow left ventricular assist devices..

    Article  PubMed  Google Scholar 

  65. Gordon RJ, Quagliarello B, Lowy FD. Ventricular assist device-related infections. Lancet Infect Dis. 2006;6:426–37.

    Article  PubMed  Google Scholar 

  66. Malani PN, Dyke DB, Pagani FD, Chenoweth CE. Nosocomial infections in left ventricular assist device recipients. Clin Infect Dis. 2002;34:1295–300.

    Article  PubMed  Google Scholar 

  67. Aslam S, Hernandez M, Thornby J, et al. Risk factors and outcomes of fungal ventricular-assist device infections. Clin Infect Dis. 2010;50:664–71.

    Article  PubMed  Google Scholar 

  68. Simon D, Fischer S, Grossman A, et al. Left ventricular assist device-related infection: treatment and outcome. Clin Infect Dis. 2005;40:1108–15.

    Article  PubMed  Google Scholar 

  69. Sivaratnam K, Duggan JM. Left ventricular assist device infections: three case reports and a review of the literature. ASAIO J. 2002;48:2–7.

    Article  PubMed  Google Scholar 

  70. Poston RS, Husain S, Sorce D, et al. LVAD bloodstream infections: therapeutic rationale for transplantation after LVAD infection. J Heart Lung Transplant. 2003;22:914–21.

    Article  PubMed  Google Scholar 

  71. Sinha P, Chen JM, Flannery M, et al. Infections during left ventricular assist device support do not affect posttransplant outcomes. Circulation. 2000;102 suppl 3:III194–9.

    PubMed  CAS  Google Scholar 

  72. Ankersmit HJ, Edwards NM, Schuster M, et al. Quantitative changes in T-cell populations after left ventricular assist device implantation: relationship to T-cell apoptosis and soluble CD95. Circulation. 1999;100(suppl):II211–5.

    PubMed  CAS  Google Scholar 

  73. Ankersmit HJ, Tugulea S, Spanier T, et al. Activation-induced T-cell death and immune dysfunction after implantation of left-ventricular assist device. Lancet. 1999;354:550–5.

    Article  PubMed  CAS  Google Scholar 

  74. John R. Current axial-flow devices—the HeartMate II and Jarvik 2000 left ventricular assist devices. Semin Thorac. 2008;20:264–72.

    Article  Google Scholar 

  75. Itescu S, John R. Interactions between the recipient immune system and the left ventricular assist device surface: immunological and clinical implications. Ann Thorac Surg. 2003;75 suppl 6:S58–65.

    Article  PubMed  Google Scholar 

  76. Gordon SM, Schmitt SK, Jacobs M, et al. Nosocomial bloodstream infections in patients with implantable left ventricular assist devices. Ann Thorac Surg. 2001;72:725–30.

    Article  PubMed  CAS  Google Scholar 

  77. Pae WE, Connell JM, Adelowo A, et al. Does total implantability reduce infection with the use of a left ventricular assist device? The LionHeart experience in Europe. J Heart Lung Transplant. 2007;26:219–29.

    Article  PubMed  Google Scholar 

  78. Copeland JG, Smith RG, Arabia FA, et al. Cardiac replacement with a total artificial heart as a bridge to transplantation. N Engl J Med. 2004;351:859–67.

    Article  PubMed  CAS  Google Scholar 

  79. • Copeland JG, Smith RG, Bose RK, et al. Risk factor analysis for bridge to transplantation with the CardioWest total artificial heart. Ann Thorac Surg. 2008;85:1639–44. The authors reported the risk factor profiles for bridge to transplantation with the CardioWest total artificial heart and summarized reports for other cardiac devices..

    Article  PubMed  Google Scholar 

  80. Platis A, Larson DF. CardioWest temporary total artificial heart. Perfusion. 2009;24:341–6.

    Article  PubMed  Google Scholar 

  81. Roussel JC, Sénage T, Baron O, et al. CardioWest (Jarvik) total artificial heart: a single-center experience with 42 patients. Ann Thorac Surg. 2009;87:124–30.

    Article  PubMed  Google Scholar 

  82. Arabia FA, Copeland JG, Smith RG, et al. International experience with the CardioWest total artificial heart as a bridge to heart transplantation. Eur J Cardiothorac Surg. 1997;11(Suppl):S5–S10.

    Article  PubMed  Google Scholar 

  83. Frazier OH, Dowling RD, Gray Jr LA, et al. The total artificial heart: where we stand. Cardiology. 2004;101:117–21.

    Article  PubMed  CAS  Google Scholar 

  84. Barbato E, Marco J, Wijins W. Direct stenting. Eur Heart J. 2003;24:394–403.

    Article  PubMed  Google Scholar 

  85. Kaufmann BA, Kaiser C, Pfisterer ME, Bonetti PO. Coronary stent infection: a rare but severe complication of percutaneous coronary intervention. Swiss Med Wkly. 2005;135:483–7.

    PubMed  Google Scholar 

  86. Schoenkerman AB, Lundstrom RJ. Coronary stent infections: a case series. Catheter Cardiovasc Interv. 2009;73:74–6.

    Article  PubMed  Google Scholar 

  87. Cassar A, Holmes Jr DR, Rihal CS, Gersh BJ. Chronic coronary artery disease: diagnosis and management. Mayo Clin Proc. 2009;84:1130–46.

    Article  PubMed  CAS  Google Scholar 

  88. Banai S, Selitser V, Keren A, et al. Prospective study of bacteremia after cardiac catheterization. Am J Cardiol. 2003;92:1004–7.

    Article  PubMed  Google Scholar 

  89. Hoffman M, Baruch R, Kaplan E, et al. Coronary stent bacterial infection with multiple organ septic emboli. Eur J Intern Med. 2005;16:123–5.

    Article  PubMed  Google Scholar 

  90. Costa MA, Simon DI. Molecular basis of restenosis and drug-eluting stents. Circulation. 2005;111:2257–73.

    Article  PubMed  Google Scholar 

Download references

Disclosures

No potential conflicts of interest relevant to this article were reported.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to George M. Viola.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Viola, G.M., Darouiche, R.O. Cardiovascular Implantable Device Infections. Curr Infect Dis Rep 13, 333–342 (2011). https://doi.org/10.1007/s11908-011-0187-7

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11908-011-0187-7

Keywords

Navigation