Nonvalvular cardiovascular device-related infections.

More than a century ago, Osler took numerous syndrome descriptions of cardiac valvular infection that were incomplete and confusing and categorized them into the cardiovascular infections known as infective endocarditis. Because he was both a clinician and a pathologist, he was able to provide a meaningful outline of this complex disease. Technical advances have allowed us to better subcategorize infective endocarditis on the basis of microbiological etiology. More recently, the syndromes of infective endocarditis and endarteritis have been expanded to include infections involving a variety of cardiovascular prostheses and devices that are used to replace or assist damaged or dysfunctional tissues (Table 1). Taken together, infections of these novel intracardiac, arterial, and venous devices are frequently seen in medical centers throughout the developed world. In response, the American Heart Association’s Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease wrote this review to assist and educate clinicians who care for an increasing number of patients with nonvalvular cardiovascular device–related infections. Because timely guidelines1,2 exist that address the prevention and management of intravascular catheter–related infections, these device-related infections are not discussed in the present Statement. This review is divided into two broad sections. The first section examines general principles for the evaluation and management of infection that apply to all nonvalvular cardiovascular devices. Despite the marked variability in composition, structure, function, and frequency of infection among the various types of nonvalvular cardiovascular devices reviewed in this article, there are several areas of commonality for infection of these devices. These include clinical manifestations, microbiology, pathogenesis, diagnosis, treatment, and prevention. The second section addresses each device and describes unique clinical features of infection. Each device is placed into one of 3 categories— intracardiac, arterial, or venous—for discussion. General Principles Clinical Manifestations The specific signs and symptoms associated with an infection of a nonvalvular cardiovascular device depend on the location of the infected portion(s) of the device. Clinical manifestations of infected intravascular or endovascular portions of a device are similar to those seen in infective endocarditis or endarteritis.3,4 Fever is present in most cases. Embolic events are also commonplace and involve either the pulmonary or systemic vasculature, according to the location of the infected device. Sepsis with shock and organ dysfunction is present in some acute presentations caused by virulent pathogens such as Staphylococcus aureus and Pseudomonas aeruginosa. Subacute to chronic presentations are characteristic of infections produced by less aggressive microorganisms. Immunemediated events are occasionally seen with chronic infections and include immune complex–mediated nephritis and vasculitis. These infections can present as bacteremia with fever and no other clinical findings. For devices that have infection involving percutaneous drivelines, there can be local pain, erythema, induration, warmth, and purulent drainage at the percutaneous exit site, often in association with bacteremia. For devices that are implanted subcutaneously, infection at the site can present with local findings of cellulitis or abscess formation, with or without bacteremia (Figure 1). Pseudoaneurysms develop in some cases of infection at vascular graft anastomosis sites and present as pulsatile masses. Occlusion of a graft may lead to distal manifestations of ischemia or necrosis.