Skip to main content
SpringerLink
Log in

Building Up the Diagnosis of Cardiac Device Infections: The Role of Imaging

  • Chapter
  • First Online:
Infections of Cardiac Implantable Devices

  • 397 Accesses

Abstract

Among the complications of cardiac implantable electronic devices (CIED), infections represent one of the nastiest in view of the heavy impact on clinical outcomes and associated costs for healthcare systems. CIED-related infections (CIEDI) can present with several different clinical manifestations increasing the complexity of the diagnostic process. Clinical examination, laboratory exams, blood cultures, and swabs all are mandatory steps for the diagnostic process, similarly to what occurs during diagnosis of endocarditis. However, since signs and symptom may be mild or confusing, imaging has a key role in providing the correct diagnosis. In the present chapter we will discuss the various aspects of echocardiography (transthoracic, transesophageal, and intracardiac) in ruling out CIEDI diagnosis. Later we will discuss the role of computer tomography and magnetic resonance in view of their increasing use in the management of endocarditis, focusing on their pros and cons in the CIEDI setting. Finally, we will focus on nuclear imaging discussing all the various aspects of 18F-FDG PET scan and white blood cell SPET for diagnosis of CIEDI elucidating the advantages among the other imaging techniques but also clarifying how to obtain the maximum from these tools. Notably, the role of imaging techniques is not limited to help defining the diagnosis of CIEDI. For this reason we will dedicate a large part of this chapter to discuss their role in assessment of the extension of the infectious process, detection of complications, supporting transvenous lead extraction (TLE) procedures, planning CIED reimplantation, and helping in predicting post-TLE risk of reinfection or death.

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

Access this chapter

Log in via an institution
eBook
USD 16.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 109.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 159.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Similar content being viewed by others

References

  1. Podoleanu C, Deharo JC. Management of Cardiac Implantable Electronic Device Infection. Arrhythm Electrophysiol Rev. 2014;3(3):184–9.

    PubMed  PubMed Central  Google Scholar 

  2. Li JS, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis. 2000;30(4):633–8.

    CAS  PubMed  Google Scholar 

  3. Habib G, et al. ESC guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J. 2015;36(44):3075–128.

    PubMed  Google Scholar 

  4. Habib G, et al. Recommendations for the practice of echocardiography in infective endocarditis. Eur J Echocardiogr. 2010;11(2):202–19.

    PubMed  Google Scholar 

  5. 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(2):339–44.

    PubMed  Google Scholar 

  6. Grammes JA, 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(9):886–94.

    PubMed  Google Scholar 

  7. Erba PA, et al. Recommendations on nuclear and multimodality imaging in IE and CIED infections. Eur J Nucl Med Mol Imaging. 2018;45(10):1795–815.

    PubMed  Google Scholar 

  8. Diemberger I, et al. From lead management to implanted patient management: indications to lead extraction in pacemaker and cardioverter-defibrillator systems. Expert Rev Med Devices. 2011;8(2):235–55.

    PubMed  Google Scholar 

  9. Victor F, et al. Pacemaker lead infection: echocardiographic features, management, and outcome. Heart. 1999;81(1):82–7.

    CAS  PubMed  PubMed Central  Google Scholar 

  10. Cacoub P, et al. Pacemaker infective endocarditis. Am J Cardiol. 1998;82(4):480–4.

    CAS  PubMed  Google Scholar 

  11. Klug D, et al. Systemic infection related to endocarditis on pacemaker leads: clinical presentation and management. Circulation. 1997;95(8):2098–107.

    CAS  PubMed  Google Scholar 

  12. Almomani A, Siddiqui K, Ahmad M. Echocardiography in patients with complications related to pacemakers and cardiac defibrillators. Echocardiography. 2014;31(3):388–99.

    PubMed  Google Scholar 

  13. Narducci ML, et al. Usefulness of intracardiac echocardiography for the diagnosis of cardiovascular implantable electronic device-related endocarditis. J Am Coll Cardiol. 2013;61(13):1398–405.

    PubMed  Google Scholar 

  14. Sohail MR, et al. Management and outcome of permanent pacemaker and implantable cardioverter-defibrillator infections. J Am Coll Cardiol. 2007;49(18):1851–9.

    PubMed  Google Scholar 

  15. Massoure PL, et al. Pacemaker endocarditis: clinical features and management of 60 consecutive cases. Pacing Clin Electrophysiol. 2007;30(1):12–9.

    PubMed  Google Scholar 

  16. Baman TS, et al. Risk factors for mortality in patients with cardiac device-related infection. Circ Arrhythm Electrophysiol. 2009;2(2):129–34.

    PubMed  Google Scholar 

  17. Horstkotte D, et al. Guidelines on prevention, diagnosis and treatment of infective endocarditis executive summary; the task force on infective endocarditis of the European society of cardiology. Eur Heart J. 2004;25(3):267–76.

    PubMed  Google Scholar 

  18. Lo R, et al. Incidence and prognosis of pacemaker lead-associated masses: a study of 1,569 transesophageal echocardiograms. J Invasive Cardiol. 2006;18(12):599–601.

    PubMed  Google Scholar 

  19. Downey BC, et al. Incidence and significance of pacemaker and implantable cardioverter-defibrillator lead masses discovered during transesophageal echocardiography. Pacing Clin Electrophysiol. 2011;34(6):679–83.

    PubMed  Google Scholar 

  20. Anwar AM, et al. Assessment of normal tricuspid valve anatomy in adults by real-time three-dimensional echocardiography. Int J Cardiovasc Imaging. 2007;23(6):717–24.

    PubMed  PubMed Central  Google Scholar 

  21. Bongiorni MG, et al. Intracardiac echocardiography in patients with pacing and defibrillating leads: a feasibility study. Echocardiography. 2008;25(6):632–8.

    PubMed  Google Scholar 

  22. Oestreich BA, et al. Use of transesophageal echocardiography to improve the safety of Transvenous Lead extraction. JACC Clin Electrophysiol. 2015;1(5):442–8.

    PubMed  Google Scholar 

  23. Ram H, et al. The AngioVac device and its anesthetic implications. J Cardiothorac Vasc Anesth. 2017;31(3):1091–102.

    PubMed  Google Scholar 

  24. Le Dolley Y, et al. Diagnosis of cardiac device-related infective endocarditis after device removal. JACC Cardiovasc Imaging. 2010;3(7):673–81.

    PubMed  Google Scholar 

  25. Diemberger I, et al. Predictors of long-term survival free from relapses after extraction of infected CIED. Europace. 2018;20(6):1018–27.

    PubMed  Google Scholar 

  26. Narducci ML, et al. Presence of 'ghosts' and mortality after transvenous lead extraction. Europace. 2017;19(3):432–40.

    PubMed  Google Scholar 

  27. Chen W, Sajadi MM, Dilsizian V. Merits of FDG PET/CT and functional molecular imaging over anatomic imaging with echocardiography and CT angiography for the diagnosis of cardiac device infections. JACC Cardiovasc Imaging. 2018;11(11):1679–91.

    PubMed  Google Scholar 

  28. Entrikin DW, et al. Imaging of infective endocarditis with cardiac CT angiography. J Cardiovasc Comput Tomogr. 2012;6(6):399–405.

    PubMed  Google Scholar 

  29. Gomes A, et al. Diagnostic value of imaging in infective endocarditis: a systematic review. Lancet Infect Dis. 2017;17(1):e1–e14.

    PubMed  Google Scholar 

  30. Hryniewiecki T, et al. The usefulness of cardiac CT in the diagnosis of perivalvular complications in patients with infective endocarditis. Eur Radiol, 2019.

    Google Scholar 

  31. Prendergast BD, Tornos P. Surgery for infective endocarditis: who and when? Circulation. 2010;121(9):1141–52.

    PubMed  Google Scholar 

  32. Feuchtner GM, et al. Multislice computed tomography in infective endocarditis: comparison with transesophageal echocardiography and intraoperative findings. J Am Coll Cardiol. 2009;53(5):436–44.

    PubMed  Google Scholar 

  33. Diemberger I, et al. From lead management to implanted patient management: systematic review and meta-analysis of the last 15 years of experience in lead extraction. Expert Rev Med Devices. 2013;10(4):551–73.

    CAS  PubMed  Google Scholar 

  34. Bongiorni MG, et al. The European Lead extraction ConTRolled (ELECTRa) study: a European heart rhythm association (EHRA) registry of transvenous lead extraction outcomes. Eur Heart J. 2017;38(40):2995–3005.

    PubMed  Google Scholar 

  35. Pizzi MN, et al. Improving the diagnosis of infective endocarditis in prosthetic valves and Intracardiac devices with 18F-fluordeoxyglucose positron emission tomography/computed tomography angiography: initial results at an infective endocarditis referral center. Circulation. 2015;132(12):1113–26.

    PubMed  Google Scholar 

  36. Tanis W, et al. CT angiography and (1)(8)F-FDG-PET fusion imaging for prosthetic heart valve endocarditis. JACC Cardiovasc Imaging. 2013;6(9):1008–13.

    PubMed  Google Scholar 

  37. Zatorska K, et al. The usefulness of magnetic resonance imaging in the diagnosis of infectious endocarditis. J Heart Valve Dis. 2015;24(6):767–75.

    PubMed  Google Scholar 

  38. Dursun M, et al. The utility of cardiac MRI in diagnosis of infective endocarditis: preliminary results. Diagn Interv Radiol. 2015;21(1):28–33.

    PubMed  Google Scholar 

  39. Sievers B, et al. Cardiovascular magnetic resonance imaging demonstrates mitral valve endocarditis. Am J Med. 2003;115(8):681–2.

    PubMed  Google Scholar 

  40. Pollak Y, Comeau CR, Wolff SD. Staphylococcus aureus endocarditis of the aortic valve diagnosed on MR imaging. AJR Am J Roentgenol. 2002;179(6):1647.

    PubMed  Google Scholar 

  41. Snygg-Martin U, et al. Cerebrovascular complications in patients with left-sided infective endocarditis are common: a prospective study using magnetic resonance imaging and neurochemical brain damage markers. Clin Infect Dis. 2008;47(1):23–30.

    PubMed  Google Scholar 

  42. Cooper HA, et al. Subclinical brain embolization in left-sided infective endocarditis: results from the evaluation by MRI of the brains of patients with left-sided intracardiac solid masses (EMBOLISM) pilot study. Circulation. 2009;120(7):585–91.

    PubMed  Google Scholar 

  43. Shulman RM, Hunt B. Cardiac implanted electronic devices and MRI safety in 2018-the state of play. Eur Radiol. 2018;28(10):4062–5.

    PubMed  Google Scholar 

  44. Sarrazin JF, et al. Role of radionuclide imaging for diagnosis of device and prosthetic valve infections. World J Cardiol. 2016;8(9):534–46.

    PubMed  PubMed Central  Google Scholar 

  45. Erba PA, et al. Radiolabeled WBC scintigraphy in the diagnostic workup of patients with suspected device-related infections. JACC Cardiovasc Imaging. 2013;6(10):1075–86.

    PubMed  Google Scholar 

  46. Rouzet F, et al. Respective performance of 18F-FDG PET and radiolabeled leukocyte scintigraphy for the diagnosis of prosthetic valve endocarditis. J Nucl Med. 2014;55(12):1980–5.

    CAS  PubMed  Google Scholar 

  47. Erba PA, et al. Added value of 99mTc-HMPAO-labeled leukocyte SPECT/CT in the characterization and management of patients with infectious endocarditis. J Nucl Med. 2012;53(8):1235–43.

    CAS  PubMed  Google Scholar 

  48. Zhu A, Lee D, Shim H. Metabolic positron emission tomography imaging in cancer detection and therapy response. Semin Oncol. 2011;38(1):55–69.

    CAS  PubMed  PubMed Central  Google Scholar 

  49. Som P, et al. A fluorinated glucose analog, 2-fluoro-2-deoxy-D-glucose (F-18): nontoxic tracer for rapid tumor detection. J Nucl Med. 1980;21(7):670–5.

    CAS  PubMed  Google Scholar 

  50. Wahl RL. Targeting glucose transporters for tumor imaging: "sweet" idea, "sour" result. J Nucl Med. 1996;37(6):1038–41.

    CAS  PubMed  Google Scholar 

  51. Kostakoglu L, et al. PET-CT fusion imaging in differentiating physiologic from pathologic FDG uptake. Radiographics. 2004;24(5):1411–31.

    PubMed  Google Scholar 

  52. Coulden R, et al. Suppression of myocardial 18F-FDG uptake with a preparatory "Atkins-style" low-carbohydrate diet. Eur Radiol. 2012;22(10):2221–8.

    PubMed  Google Scholar 

  53. Persson E. Lipoprotein lipase, hepatic lipase and plasma lipolytic activity. Effects of heparin and a low molecular weight heparin fragment (Fragmin). Acta Med Scand Suppl. 1988;724:1–56.

    CAS  PubMed  Google Scholar 

  54. Vaidyanathan S, et al. FDG PET/CT in infection and inflammation--current and emerging clinical applications. Clin Radiol. 2015;70(7):787–800.

    CAS  PubMed  Google Scholar 

  55. Bleeker-Rovers CP, et al. A prospective multi-Centre study of the value of FDG-PET as part of a structured diagnostic protocol in patients with fever of unknown origin. Eur J Nucl Med Mol Imaging. 2007;34(5):694–703.

    PubMed  Google Scholar 

  56. Blockmans D. PET in vasculitis. Ann N Y Acad Sci. 2011;1228:64–70.

    PubMed  Google Scholar 

  57. Theron J, Tyler JL. Takayasu's arteritis of the aortic arch: endovascular treatment and correlation with positron emission tomography. AJNR Am J Neuroradiol. 1987;8(4):621–6.

    CAS  PubMed  Google Scholar 

  58. Teirstein AS, et al. Results of 188 whole-body fluorodeoxyglucose positron emission tomography scans in 137 patients with sarcoidosis. Chest. 2007;132(6):1949–53.

    PubMed  Google Scholar 

  59. Wang GL, et al. A meta-analysis of fluorodeoxyglucose-positron emission tomography versus scintigraphy in the evaluation of suspected osteomyelitis. Nucl Med Commun. 2011;32(12):1134–42.

    PubMed  Google Scholar 

  60. Mahmood M, et al. Meta-analysis of 18F-FDG PET/CT in the diagnosis of infective endocarditis. J Nucl Cardiol, 2017.

    Google Scholar 

  61. Vos FJ, et al. Detection of pacemaker and lead infection with FDG-PET. Eur J Nucl Med Mol Imaging. 2006;33(10):1245.

    CAS  PubMed  Google Scholar 

  62. Ahmed FZ, et al. Early diagnosis of cardiac implantable electronic device generator pocket infection using (1)(8)F-FDG-PET/CT. Eur Heart J Cardiovasc Imaging. 2015;16(5):521–30.

    PubMed  PubMed Central  Google Scholar 

  63. Bensimhon L, et al. Whole body [(18) F]fluorodeoxyglucose positron emission tomography imaging for the diagnosis of pacemaker or implantable cardioverter defibrillator infection: a preliminary prospective study. Clin Microbiol Infect. 2011;17(6):836–44.

    CAS  PubMed  Google Scholar 

  64. Cautela J, et al. Diagnostic yield of FDG positron-emission tomography/computed tomography in patients with CEID infection: a pilot study. Europace. 2013;15(2):252–7.

    PubMed  Google Scholar 

  65. Diemberger I, et al. Contribution of PET imaging to mortality risk stratification in candidates to lead extraction for pacemaker or defibrillator infection: a prospective single center study. Eur J Nucl Med Mol Imaging. 2019;46(1):194–205.

    PubMed  Google Scholar 

  66. Granados U, et al. Diagnostic accuracy of 18F-FDG PET/CT in infective endocarditis and implantable cardiac electronic device infection: a cross-sectional study. J Nucl Med. 2016;57(11):1726–32.

    CAS  PubMed  Google Scholar 

  67. Graziosi M, et al. Role of (1)(8)F-FDG PET/CT in the diagnosis of infective endocarditis in patients with an implanted cardiac device: a prospective study. Eur J Nucl Med Mol Imaging. 2014;41(8):1617–23.

    PubMed  Google Scholar 

  68. Leccisotti L, et al. Cardiovascular implantable electronic device infection: delayed vs standard FDG PET-CT imaging. J Nucl Cardiol. 2014;21(3):622–32.

    PubMed  Google Scholar 

  69. Memmott MJ, et al. The performance of quantitation methods in the evaluation of cardiac implantable electronic device (CIED) infection: a technical review. J Nucl Cardiol. 2016;23(6):1457–66.

    PubMed  Google Scholar 

  70. Sarrazin JF, et al. Usefulness of fluorine-18 positron emission tomography/computed tomography for identification of cardiovascular implantable electronic device infections. J Am Coll Cardiol. 2012;59(18):1616–25.

    PubMed  Google Scholar 

  71. Tlili G, et al. High performances of (18)F-fluorodeoxyglucose PET-CT in cardiac implantable device infections: a study of 40 patients. J Nucl Cardiol. 2015;22(4):787–98.

    PubMed  Google Scholar 

  72. Juneau D, et al. Positron emission tomography and single-photon emission computed tomography imaging in the diagnosis of cardiac implantable electronic device infection: a systematic review and meta-analysis. Circ Cardiovasc Imaging, 2017;10(sss).

    Google Scholar 

  73. Mahmood M, et al. Role of (18)F-FDG PET/CT in the diagnosis of cardiovascular implantable electronic device infections: a meta-analysis. J Nucl Cardiol, 2017.

    Google Scholar 

  74. Baddour LM, et al. Update on cardiovascular implantable electronic device infections and their management: a scientific statement from the American Heart Association. Circulation. 2010;121(3):458–77.

    PubMed  Google Scholar 

  75. Rodriguez Y, et al. Cardiac device-related endocarditis complicated by spinal abscess. Pacing Clin Electrophysiol. 2012;35(3):269–74.

    PubMed  Google Scholar 

  76. Amraoui S, et al. Contribution of PET imaging to the diagnosis of septic embolism in patients with pacing Lead endocarditis. JACC Cardiovasc Imaging. 2016;9(3):283–90.

    PubMed  Google Scholar 

  77. An HS, Seldomridge JA. Spinal infections: diagnostic tests and imaging studies. Clin Orthop Relat Res. 2006;444:27–33.

    PubMed  Google Scholar 

  78. Hilbert S, et al. Cardiovascular magnetic resonance imaging in patients with cardiac implantable electronic devices: a device-dependent imaging strategy for improved image quality. Eur Heart J Cardiovasc Imaging. 2018;19(9):1051–61.

    PubMed  Google Scholar 

  79. Bonfiglioli R, et al. (1)(8)F-FDG PET/CT diagnosis of unexpected extracardiac septic embolisms in patients with suspected cardiac endocarditis. Eur J Nucl Med Mol Imaging. 2013;40(8):1190–6.

    CAS  PubMed  Google Scholar 

  80. Van Riet J, et al. (18)F-FDG PET/CT for early detection of embolism and metastatic infection in patients with infective endocarditis. Eur J Nucl Med Mol Imaging. 2010;37(6):1189–97.

    PubMed  Google Scholar 

  81. Gupta A, Madani R, Mukhtar H. Streptococcus bovis endocarditis, a silent sign for colonic tumour. Color Dis. 2010;12(3):164–71.

    CAS  Google Scholar 

  82. Maytin M, Jones SO, Epstein LM. Long-term mortality after transvenous lead extraction. Circ Arrhythm Electrophysiol. 2012;5(2):252–7.

    CAS  PubMed  Google Scholar 

  83. Tarakji KG, et al. Risk factors for 1-year mortality among patients with cardiac implantable electronic device infection undergoing transvenous lead extraction: the impact of the infection type and the presence of vegetation on survival. Europace. 2014;16(10):1490–5.

    PubMed  Google Scholar 

  84. Boellaard R, et al. FDG PET/CT: EANM procedure guidelines for tumour imaging: version 2.0. Eur J Nucl Med Mol Imaging. 2015;42(2):328–54.

    CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Experimental, Diagnostic and Specialty Medicine, Institute of Cardiology, University of Bologna, Bologna, Italy

    Igor Diemberger & Stefano Lorenzetti

  2. Department of Experimental, Diagnostic and Specialty Medicine, Institute of Nuclear Medicine, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy

    Rachele Bonfiglioli

Authors
  1. Igor Diemberger
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Stefano Lorenzetti
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Rachele Bonfiglioli
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Igor Diemberger .

Editor information

Editors and Affiliations

  1. Cardiology Institute, University of Bologna, Bologna, Italy

    Igor Diemberger

  2. Cardiology Department, Policlinico, University of Modena and Reggio Emilia, Modena, Italy

    Giuseppe Boriani

Rights and permissions

Reprints and permissions

Copyright information

© 2020 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Diemberger, I., Lorenzetti, S., Bonfiglioli, R. (2020). Building Up the Diagnosis of Cardiac Device Infections: The Role of Imaging. In: Diemberger, I., Boriani, G. (eds) Infections of Cardiac Implantable Devices. Springer, Cham. https://doi.org/10.1007/978-3-030-46255-0_5

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-46255-0_5

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-46254-3

  • Online ISBN: 978-3-030-46255-0

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation