Prevotella bivia cardiac implantable electronic device related endocarditis.

Cases of Gram-negative, anaerobic rod bacteremia and endocarditis have been increasingly recognized in recent years. This increase has been primarily observed in patients at risk for polymicrobial infections, such as those who use injection drugs and patients with diabetes mellitus. Despite a growing incidence, there are few published case reports of cardiac implantable electronic device related endocarditis secondary to Gram negative, anaerobic organisms. We present a unique case of Prevotella bivia cardiac implantable electronic device related endocarditis in a middle-aged woman with no history of injection drug use. This case highlights the increasing incidence of polymicrobial infections and anaerobic endocarditis. Additionally, it demonstrates how Prevotella bivia has the potential to cause native valve infective endocarditis as well as cardiac implantable electronic device related endocarditis.

Use of an antimicrobial pouch/envelope in the treatment of Twiddler's syndrome.

BACKGROUND: "Twiddler's syndrome" occurs when a patient consciously or subconsciously manipulates their pacemaker/defibrillator pulse generator, often resulting in lead dislodgement and device system malfunction. Once dislodgement has occurred, corrective measures include resecuring the system to the pectoralis fascia with redundant anchoring sutures. Unfortunately, patients with Twiddler's syndrome tend to have a high rate of recurrence. This study presents a case series of patients with Twiddler's syndrome and evaluates the strategy of using a nonabsorbable antimicrobial pouch to prevent recurrent lead dislodgement events. METHODS: Pacemaker and defibrillator operative reports were reviewed at a single institution over a time period of 16 years. Historical, fluoroscopic, and intraoperative findings were used to identify 21 patients with strong evidence for Twiddler's syndrome. Patient charts were retrospectively analyzed, and a cohort of 13 patients who received a nonabsorbable antimicrobial pouch was compared to a cohort of eight patients who received other corrective measures. RESULTS: The rate of "retwiddling" events was 0% in the antimicrobial pouch group versus 50% in the suture-only group (P < 0.05). CONCLUSIONS: Among patients requiring device system revision for Twiddler's syndrome, the use of nonabsorbable antimicrobial pouches was associated with significantly fewer recurrences of lead dislodgement events.

Nailed It: Conservative Management of Penetrating Injury and Potential Infection of a Cardiovascular Implantable Electronic Device.

A 47-year-old man with a history of ischemic cardiomyopathy and chronic systolic heart failure presented after he inadvertently shot himself in the left upper chest with a pneumatic nail gun, penetrating his implantable cardioverter defibrillator (ICD) generator. The device was noninterrogable, consistent with device failure. A new ICD was attached to the existing right ventricular lead, which showed no evidence of traumatic damage and normal lead parameters on interrogation. Aggressive debridement and antibiotic irrigation of the ICD pocket was performed and an antibacterial envelope was used. Bacterial culture of the ICD pocket grew Bacillus species. The patient completed a course of at least 14 days of oral clindamycin. At follow-up, there were no signs or symptoms of systemic or local wound infection.

A perioperative management algorithm for cardiac rhythm management devices: the PACED-OP protocol.

BACKGROUND: Limited data are available regarding the perioperative management of cardiac rhythm management devices (CRMDs) exposed to intraoperative electromagnetic interference. We postulated that implementation of a simple, standardized approach to CRMD management using our own institution's Pacing And Cardioverting Electronic Devices peri-Operative Protocol (the PACED-OP protocol) would be associated with a reduction in the amount of device reprogramming without an increase in CRMD-related complications. METHODS: Records of patients with CRMDs undergoing 497 consecutive surgical procedures were analyzed retrospectively. Roughly half (51%, n = 254) of these procedures occurred before implementation of the PACED-OP protocol, when patients were generally treated according to the American Society of Anesthesiologists' 2005 guidelines. These cases were compared to the remaining surgeries that occurred after implementation of the PACED-OP protocol. Records were screened for evidence of intraoperative CRMD malfunction that was directly associated with the use of electrocautery. Postoperative complications that could be indirectly or possibly linked to electrocautery-mediated CRMD malfunction were also identified. RESULTS: Implementation of the PACED-OP protocol was associated with a significant reduction in the odds of device reprogramming (adjusted odds ratio [aOR] 0.19, P < 0.001). There was no direct evidence of CRMD malfunction in either cohort. The rate of postoperative complications that could be indirectly or possibly linked with electrocautery-mediated CRMD damage did not differ significantly between cohorts (aOR = 1.37, 95% confidence interval 0.56-3.3, P = 0.49). CONCLUSION: The PACED-OP protocol implementation was associated with a significant reduction in the odds of device reprogramming without a significant difference in the odds of CRMD-related complications.

Aorto-right atrial fistula following transseptal catheterization and catheter ablation for atrial fibrillation.

Aorto-cameral fistula, either congenital or acquired, is an abnormal connection between the ascending aortic root and one of the cardiac chambers. We report a case of a 61-year-old male with history of atrial fibrillation and 2 radiofrequency ablation procedures, referred to us for surgical Cox Maze procedure. Preoperative cardiac computerized tomography revealed a fistulous connection between the aortic root and the right atrium. Later, the patient underwent successful surgical closure of the fistula during the Cox Maze procedure. In this paper, we also discuss the clinical presentation, natural history, anatomy of the interatrial septum, and management of aorto-cameral fistula.