1. Cardiovascular devices and prostheses can become infected, leading to device-related infective endocarditis (CDRIE). CDRIE is associated with high mortality. 2. Infective endocarditis can also occur in unusual sites, such as the pulmonary valve, coronary stents, septal closure devices, and the aorta in the setting of coarctation. These unusual sites of IE are often associated with underlying heart conditions or invasive procedures/devices. 3. Diagnosis of infective endocarditis requires blood cultures, echocardiography, and in some cases lead extractions to confirm the causative pathogen. Treatment involves prolonged antibiotic therapy and often complete removal of the infected

1. IE, Unusual sites & unusual pathogens
Cardiac device and vascular prostheses
Mohamad Ashraf Ahmad, MD, PhD.
Lecturer of cardiology –Assiut University

2. Introduction
• More than a century ago, Osler took
numerous syndrome descriptions of
cardiac valvular infection that were
incomplete and confusing and
categorized them into the CV
infections known as Infective
endocarditis. Sir william Osler
1849-1919

3. • More recently, the syndromes of IE and
endarteritis have been expanded to include
infections involving a variety of cardiovascular
prostheses and devices (PM, ICD, CRT,… )
that are used to replace or assist damaged or
dysfunctional tissues.

4. Usual site of IE
• Endocarditis generally refers to
inflammation on the valve leaflets.
• The valves most commonly infected are left-
sided valves.
• Infections of the tricuspid and pulmonary valves
are highly suspicious of intravenous drug abuse.

5. Unusual sites of IE
• Cardiovascular Device–Related Infections:
• Intracardiac (PM, ICD, CRT, LVAD, ASD/VSD
closure device, PDA closure, patches, …
• Arterial (Coronary and peripheral stents, vascular
grafts, patches, ……..
• Venous (IVC filter)
• Other unusual sites of IE (case reports):

7. Cardiac device related infective endocarditis:
• CDREI is a severe disease associated with
high mortality.
• The increased rates of cardiac devices
implantation coupled with increased
implantation in elderly patients with more co-
morbidities resulted in rising rate of CDREI.
• The reported incidence CDRIE varies in the
literature from 0.06% to 7%.

8. Greenspon AJ et al., J Am Coll Cardiol 2011

9. Pathogenesis CDREI:
Pocket infection
• Subcutaneous pocket containing
the device and the subcutaneous
segment of the leads.
• Caused by infection at the time of
implantation, during subsequent
surgical manipulation of the
pocket.
• If the generator or subcutaneous
electrodes erode through the skin
Deeper infection
• Infection involves the transvenous
portion of the lead, usually with
associated bacteremia and
/or endovascular infection.
• Source of Infection:
• Extension from pocket infection
• Less common, a result of
haematogenous seeding during
a bacteraemia secondary to a
distant infected focus.

10. • The consequence may be formation of
vegetations, which can be found anywhere
from the insertion vein to the SVC, on the lead
or on the tricuspid valve, as well as on the right
atrial and ventricular endocardium.

11. Risk factors:
• Renal failure, corticosteroid use,
CHF, DM, malignancy, post operative
pocket haematoma & anticoagulation
use.
Patient
factors:
• Type of intervention, device
revisions, the site of intervention, the
amount of indwelling hardware, the
use of pre-procedural temporary
pacing, failure of antimicrobial
prophylaxis, fever within the 24 h
before implantation & operator
experience.
Procedural
factors:

12. Causative pathogen:
• Staphylococci, and especially CoNS, account
for 60–80% of cases .
• Rare pathogen: Corynebacterium spp.,
Propionibacterium acnes, Gram-negative bacilli
and Candida spp.

13. Sohail R M et al., J Am Coll Cardiol 2007

14. Diagnosis:
• Systemic symptoms: Fever
(>38°C) frequently blunted
particularly in elderly, Chills,
Malaise, Anorexia, murmur
on examination,
• Local findings at generator
site: Erythema, Pain,
Swelling, Warmth,
Tenderness, Purulent
drainage, Skin ulceration,
Generator/lead erosion.
Sohail RM et al., Expert Rev Anti Infect Ther. 2010

15. • Echocardiography and blood cultures are the
cornerstones of diagnosis.
• Three or more sets of blood cultures are
recommended before initiation of antimicrobial
therapy.
• Lead-tip swap and extracted infected tissues
culture is indicated when the CIED is extracted.
• Modifications of the Duke criteria have been
proposed including local signs of infection and
pulmonary embolism as major criteria.

16. Echocardiography
• TTE: Lead vegetations and tricuspid
involvement.
• TEE allows visualization of the lead in atypical
locations, such as the proximal SVC, and of
regions that are difficult to visualize by TTE.
• ICE was recently found to be feasible and
effective in cardiac device patients.

17. TEE TTE

18. Early versus late CDRIE:
Arnold J et al., J Am Coll Cardiol 2012

19. Source of blood stream infection
Arnold J et al., J Am Coll Cardiol 2012

20. :Treatment CDRIE
Prolonged
Antibiotic
therapy
Complete
device
and lead
extraction

21. 1- Antimicrobial therapy:
• I.V. antibiotics should be initiated before
hardware removal, but after blood cultures.
• Vancomycin should be administered initially
as empirical antibiotic coverage until
microbiological results are known (CDRIE
infections are secondary to MARSA in up to
50%).
• The duration of therapy should be 4–6 weeks
in most cases.

22. 2- Device and lead extraction:
• Complete removal of the system is the
recommended treatment. Early and complete
device removal showed improvement in survival at
1 year.
• Percutaneous extraction is recommended in most
patients , however, this extractions have its own
risk.
• Transvenous lead extraction should be performed
only in centres with adequately trained teams and
immediate cardiothoracic surgery backup.
• Surgical extraction is indicated in:
• Percutaneous extraction is incomplete or impossible.
• Infected valves that necessitate valve repair or
replacement.

23. Lead extraction
• Traction
• Countertraction &
Telescoping
Sheaths
• Laser Sheath
• Evolution
Mechanical Sheath

24. • Probably yes, but in a very limited group of
selected patients.
• Too frail or sick patients.
• Patients with limited life expectancy due to
comorbidities or very old age.
• These patients must have only local infection or
pocket erosion, with exclusion of systemic infection
by blood cultures and a TEE.

25. Reimplantation
• Reassessment of the need for reimplantation.
• Reimplantation on the contralateral side.
• Blood cultures should be negative for at least
72 h before placement of a new device.
• Temporary pacing should be avoided if
possible.

26. Other unusual sites of IE

27. IE related to HOCM
The literature on IE in HOCM
is virtually confined to case
reports.
Spirito et al., circulation 1999

28. Late IE of Amplatzer ASD occluder device:
• Bacterial endocarditis
following ASD closure using
Amplatzer device in pediatric
is extremely rare
• Case report of 10-year-old
girl who developed late
bacterial endocarditis, 6
years after placement of an
Amplatzer atrial septal
occluder device.
Jha NK etal., world J cardiol 2015

29. :IE in Interatrial septal aneurysm
• A 34-year-old man was admitted for recurrent fever and
non-productive cough for 2 months. He suffered from
an advanced adenocarcinoma.
• Echocardiography was performed due to persistent
bacteraemia with methicillin-resistant Staphyloccus
aureus.
Shuenn J et al.,
Heart Asia 2011

30. Pulmonary valve endocarditis:
• The pulmonic valve is the least commonly
involved valve in infective endocarditis. PV
endocarditis is usually associated with tricuspid
valve endocarditis, and isolated pulmonic valve
endocarditis is exceedingly rare.
• The predisposing factors include a congenitally
anomalous pulmonic valve, intravenous drug
abuse, malignancy, the presence of indwelling
pulmonary artery catheters, Postpartum and
postabortion states.

31. Case of isolated PV endocarditis
Alcoholic and was malnourished patient
with isolated pulmonic valve endocarditis
caused by group B streptococcus was
diagnosed with TEE.
Akram et al., Angiology 2001

32. Coronary stent infection
• Although rare, coronary artery stent infections are
associated with a high mortality rate.
• Case report of 66-year-old woman who had undergone
a difficult PCI to RCA with 3 overlapping stents.
• Presented with weakness, malaise, fever and rigor as
well as midsternal chest pain.
• Blood cultures grew MRSA. Antibiotic was initiated.
• Few days later, The patient experienced cardiac arrest
with pulseless electrical activity and died.
• Autopsy revealed the cause of death to be pericardial
tamponade due to rupture of the right ventricular
myocardium.
• The stented portion of the RCA was enveloped by an
abscess.
Elieson M et al., TEX Heart Inst J , 2012

33. IE after TAVR
• IE after TAVR is a rare but serious
complication.
• A 72 year old lady complained of a 3
week history of feeling hot, sweaty,
fatigue and poor appetite.
• She had TAVR 4 years ago.
• Blood cultures grew Enterococcus
faecalis on three separate culture
samples.
Conor McQuillan, http://bjcahorizons.com/

34. Aortic coarctation endarteritis