Clinical Characteristics and Outcome of Infective Endocarditis Involving Implantable Cardiac Devices

Apr 24, 2012
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Authors:
Athan E, Chu VH, Tattevin P, et al., on behalf of the ICE-PCS Investigators.
Citation:
JAMA 2012;307:1727-1735.
Summary By:
Fred Morady, MD, FACC

Study Questions:

What are the clinical features and outcomes of cardiac device infective endocarditis (CDIE)?

Methods:

Cases of CDIE were identified in this multicenter, prospective observational study of 2,760 patients with IE. The primary outcomes were hospital mortality and 1-year mortality.

Results:

CDIE was diagnosed in 6.4% (177 patients, median age 71 years) of the total cohort. The majority of patients (86%) had a permanent pacemaker. Blood cultures were positive in 84.2% of patients, with the most common pathogens being Staphylococcus aureus (35%) and coagulase-negative staphylococci (31.6%). Vegetation on a cardiac device lead was observed by echocardiography in 82.3% of patients. Coexisting valve infection was present in 37.3% of patients. The device and leads were extracted during the index hospitalization in 80% of patients. In-hospital mortality was 14.7% and 1-year mortality was 28.8%. Device extraction during the index hospitalization was associated with approximately a 50% higher probability of 1-year survival.

Conclusions:

The authors concluded that CDIE is associated with high mortality. The risk of death is higher when the device is not extracted during the index hospitalization.

Perspective:

Because this was an observational study, the reason that 1-year survival was higher in patients who underwent early device extraction is unclear. It is possible that early device extraction was directly responsible for improved survival. However, it also is possible that there was a selection bias against early extraction in patients with more persistent sepsis or more severe comorbidities, and that these factors accounted for a higher risk of death.

Keywords: Staphylococcus, Risk, Hospital Mortality, Sepsis, Comorbidity, Staphylococcus aureus, Endocarditis, Bacterial, Staphylococcal Infections, Selection Bias, Coagulase, Pacemaker, Artificial, Probability, Hospitalization, Echocardiography


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