Cacoub P, Leprince P, Nataf P, Hausfater P, Dorent R, Wechsler B, Bors V, Pavie A, Piette J C, Gandjbakhch I
Department of Internal Medicine, Hôpital La Pitié-Salpétrière, Paris, France.
Am J Cardiol. 1998 Aug 15;82(4):480-4. doi: 10.1016/s0002-9149(98)00365-8.
We identified 33 patients with definite pacemaker endocarditis--that is, with direct evidence of infective endocarditis, based on surgery or autopsy histologic findings of or bacteriologic findings (Gram stain or culture) of valvular vegetation or electrode-tip wire vegetation. Most of the patients (75%) were > or = 60 years of age (mean 66 +/- 3; range 21 to 86). Pouch hematoma or inflammation was common (58%), but other predisposing factors for endocarditis were rare. At the time that pacemaker endocarditis was found, the mean number of leads was 2.4 +/- 1.1 (range 1 to 7). The interval from the last procedure to diagnosis of endocarditis was 20 +/- 4 months (range 1 to 72). Endocarditis appeared after pacemaker implantation, early (< 3 months) in 10 patients and late (> or = 3 months) in 23 patients. Fever was the most common symptom, being isolated in 36%, associated with a poor general condition in 24%, and associated with septic shock in 9%. Transthoracic echocardiography showed vegetations in only 2 of 9 patients. Transesophageal echocardiography demonstrated the presence of lead vegetations (n = 20) or tricuspid vegetations (n = 3) in 23 of 24 patients (96%; p <0.0001 compared with transthoracic echocardiography). Pulmonary scintigraphy showed a typical pulmonary embolization in 7 of 17 patients (41%). Pathogens were mainly isolated from blood (82%) and lead (91%) cultures. The major pathogens causing pacemaker endocarditis were Staphylococcus epidermidis (n = 17) and S. aureus (n = 7). S. epidermidis was found more often in early than in late endocarditis (90% vs 50%; p = 0.05). All patients were treated with prolonged antibiotic regimens before and after electrode removal. Electrode removal was achieved by surgery (n = 29) or traction (n = 4). Associated procedures were performed in 9 patients. After the intensive care period, only 17 patients needed a new permanent pacemaker. Overall mortality was 24% after a mean follow-up period of 22 +/- 4 months (range 1 to 88). Eight patients who were significantly older (74 +/- 3 vs 63 +/- 3 years; p = 0.05) died < or = 2 months after electrode removal, whereas 25 were alive and asymptomatic.
我们确定了33例明确的起搏器心内膜炎患者，即根据手术或尸检的组织学结果，或瓣膜赘生物或电极尖端导线赘生物的细菌学结果（革兰氏染色或培养），有感染性心内膜炎的直接证据。大多数患者（75%）年龄≥60岁（平均66±3岁；范围21至86岁）。囊袋血肿或炎症很常见（58%），但其他心内膜炎的易感因素很少见。在发现起搏器心内膜炎时，导线的平均数量为2.4±1.1（范围1至7）。从最后一次手术到心内膜炎诊断的间隔时间为20±4个月（范围1至72）。心内膜炎出现在起搏器植入后，10例患者为早期（<3个月），23例患者为晚期（≥3个月）。发热是最常见的症状，单独出现的占36%，伴有全身状况差的占24%，伴有感染性休克的占9%。经胸超声心动图仅在9例患者中的2例显示有赘生物。经食管超声心动图在24例患者中的23例（96%）显示有导线赘生物（n = 20）或三尖瓣赘生物（n = 3）（与经胸超声心动图相比，p<0.0001）。肺闪烁扫描在17例患者中的7例（41%）显示典型的肺栓塞。病原体主要从血液（82%）和导线（91%）培养物中分离出来。引起起搏器心内膜炎的主要病原体是表皮葡萄球菌（n = 17）和金黄色葡萄球菌（n = seven）。表皮葡萄球菌在早期心内膜炎中比晚期更常见（90%对50%；p = 0.05）。所有患者在拔除电极前后均接受了长期抗生素治疗。通过手术（n = 29）或牵引（n = 4）实现了电极拔除。9例患者进行了相关手术。在重症监护期后，只有17例患者需要新的永久性起搏器。平均随访22±4个月（范围1至88）后，总死亡率为24%。8例年龄明显较大的患者（74±3岁对63±3岁；p = 0.05）在拔除电极后≤2个月死亡，而25例患者存活且无症状。
