Temporary Transvenous Pacing Research Articles

Temporary transvenous cardiac pacing in cathlab - myocardial infarction versus other causes - differences, complications, and prognosis. Data from a single-center retrospective analysis.

Transvenous temporary cardiac pacing (TTCP) is a lifesaving procedure, but the incidence of complications and prognosis depends on the underlying cause. The aim of this study was to compare the characteristics, complications, and prognosis in patients with myocardial infarction (MI) requiring TTCP vs. patients with TTCP due to other causes. The present analysis involved 244 cases in whom TTCP was performed between 2017 and 2021 in a high-volume cathlab. All the procedures were performed by an interventional cardiologist. MI constituted 46.3% of the patients (n = 113), including 63 ST-segment elevation MI patients (55.75%). Non-MI patients (control group) consisted of patients with any cause of bradycardia requiring TTCP. Myocardial infarction patients requiring TTCP are younger and have a higher prevalence of hypertension and heart failure. The pacing lead is more frequently inserted during asystole/resuscitation, and pacing was needed for a longer time. MI patients required cardiac implantable electronic device implantation less frequently than in other causes (22% vs. 82%, p < 0.01). The incidence of TTCP complications did not differ. The incidence of in-hospital death was 6.5-fold higher in TTCP patients with MI. Logistic regression showed MI to be a strong predictor of in-hospital death (odds ratio: 8.1; 95% confidence interval: 1.3-57.9). In-hospital mortality in MI patients requiring TTCP is 6.5-fold higher than in other patients with bradycardia. The complication rate of TTCP is similar in MI and non-MI patients. It is not TTCP but the severity of MI itself and the fact that a pacing lead is frequently implanted in asystole or during resuscitation that is responsible for the higher mortality rate.

Emergency transvenous temporary pacing during rotational atherectomy.

Rotational atherectomy (RA) during percutaneous coronary intervention may cause transient bradycardia or a higher-degree heart block. Traditionally, some operators use prophylactic transvenous pacing wire (TPW) to avoid haemodynamic complications associated with bradycardia. We sought to establish the frequency of bail-out need for emergency TPW insertion in patients undergoing RA that have received no upfront TPW insertion. We performed a single-centre retrospective study of all patients undergoing RA between October 2009 and October 2022. Patient characteristics, procedural variables, and in-hospital complications were registered. A total of 331 patients who underwent RA procedure were analysed. No patients underwent prophylactic TPW insertion. The mean age was 73.3 ± 9.1 years, 71.6% (n = 237) were male, while nearly half of the patients were diabetic [N = 158 (47.7%)]. The right coronary artery was the most common target for RA (40.8%), followed by the left anterior descending (34.1%), left circumflex (14.8%), and left main stem artery (10.3%). Altogether 20 (6%) patients required intraprocedural atropine therapy. Emergency TPW insertion was needed in one (0.3%) patient only. Eight (2.4%) patients died, although only one (0.3%) was adjudicated as being possibly related to RA-induced bradycardia. Five patients (1.5%) had ventricular fibrillation arrest, while nine (2.7%) required cardiopulmonary resuscitation. Six (1.8%) procedures were complicated by coronary perforation, two (0.6%) were complicated by tamponade, while 17 (5.1%) patients experienced vascular access complications. Bail-out transvenous temporary pacing is very rarely required during RA. A standby temporary pacing strategy seems reasonable and may avoid unnecessary TPW complications compared with routine use.

SAT484 High Degree AV Block And Sinus Arrest: Cardiovascular Manifestations Of Myxedema Coma

Abstract Disclosure: J. Bosques-Lorenzo: None. P. Rivera: None. J. Colon-Castellano: None. Y. Otero-Dominguez: None. Bosques-Lorenzo Jaymilitte, Rivera-Cariño Patricia, Colon-Castellano Janet, Otero-Dominguez Yomaira. Background: Myxedema coma is a rare and life-threatening complication of severe hypothyroidism. The most common presenting symptoms are altered mentation, hypothermia, edema, and respiratory depression. The cardiovascular system is often involved, in the form of sick sinus syndrome, bradycardia, low voltage QRS complex, QT prolongation, and rarely cardiac arrest. Here we present a case of myxedema coma complicated with high degree AV block and sinus arrest. Clinical Case: A 84 year-old man with history of hypothyroidism on levothyroxine 125 mcg, presented to the ER due to disorientation, bilateral leg edema, and abdominal discomfort for 3 days. Vital signs revealed a temperature of 97.5 F, HR of 60bpm, BP 174/88 mmHg, and oxygen saturation of 100% at room air. Physical exam was pertinent for bilateral lower extremity edema, facial puffiness, macroglossia, slow mentation, and scattered rales on lung auscultation. Laboratories showed an elevated TSH (296.8 uIU/mL), with low total T3 and free T4 (45.03 ng/dL and 0.228 ng/dL respectively) with a myxedema score of 45. Altered renal parameters as per BUN and creatinine levels (83.4 mg/dL and 5.75 mg/dL) without electrolytes disturbances and elevated CPK (1250 U/L). Infectious process was ruled out. Chest X-ray showed vascular congestion. Echocardiogram showed a small pericardial effusion. Patient was admitted to ICU and started on IV Levothyroxine, along with hydrocortisone. Liothyronine was initially not available. On second admission day, the patient developed hypothermia (94.3 F) which was managed with passive warming. Telemetry monitoring recorded multiple episodes of bradycardia raging from 30 to 50 bpm, high-degree AV block, and one episode of sinus arrest of 15 seconds with self-resolution. Altered mentation persisted for which endotracheal intubation was performed to secure airway. A temporary transvenous pacing was placed emergently. Levothyroxine dose was further adjusted and liothyronine was initiated. After a few days of treatment, patient demonstrated clinical improvement that was supported with follow up thyroid function test. Patient was extubated and transitioned to oral levothyroxine. Nevertheless, he remained dependent of transvenous pacing for which permanent pacemaker placement was coordinated. Conclusion: Cardiovascular complications in myxedema coma are associated with poor prognosis with a mortality approaching 80%. Few cases of sinus or cardiac arrest associated to Myxedema coma have been reported in the literature. In this case, the patient developed high-degree AV block with concomitant sinus arrest despite prompt initiation of intravenous thyroid hormone. Prompt identification of cardiovascular involvement can prevent cardiovascular morbidity and mortality in myxedema coma. Presentation Date: Saturday, June 17, 2023

A Systematic Review of Short-Term Outcomes of Leadless Pacemaker Implantation After Transvenous Lead Removal of Infected Cardiac Implantable Electronic Device

The outcomes of leadless pacemaker (LP) implantation after transvenous lead removal (TLR) of infected cardiac implantable electronic devices (CIEDs) are not well-established. This study sought to describe the outcomes of LP implantation after TLR of infected CIED. We conducted a literature search using PubMed and Embase for a combination of terms including LP implantation, transvenous lead extraction, TLR, transvenous lead explant, infected CIED, infected pacemaker, and infected implantable cardioverter defibrillator. The inclusion criterion was LP implantation after TLR of infected CIED. The exclusion criterion was TLR for noninfectious reasons. Study end points included procedural complications and LP infection during follow-up. Of 132 publications reviewed, 13 studies with a total of 253 patients (74±14 years of age, 174 [69%] males) were included. The most common indication of the initial device implantations was a high-degree atrioventricular block (n=100 of 253, 39.5%). Of the 253 patients included, 105 patients (41.5%) underwent concomitant LP implantation during the TLR procedure, and 36 patients (14.2%) had temporary transvenous pacing as a bridge from TLR to LP implantation. Of the 148 patients with data on the type of CIED infection, 56.8% had systemic CIED infection and 43.2% had isolated pocket infection. Staphylococcus aureus was the most common causative organism in 33% of the reported patients. The LP was implanted an average of 5.4±10.7 days after TLR of infected CIED. During the LP implantation, 1 patient (0.4%) had unsuccessful implantation because of an intraprocedural complication requiring sternotomy. After LP implantation, 2 patients (0.8%) developed groin hematoma, 2 patients (0.8%) developed femoral arteriovenous fistula, and 1 patient (0.4%) developed pericardial effusion requiring pericardiocentesis. During a mean follow-up of 11.3±10.6 months, 3 patients (1.2%) developed pacemaker syndrome, 1 patient (0.4%) developed acute on chronic heart failure exacerbation, and only 1 patient (0.4%) developed LP-related infection requiring LP retrieval. This study suggests that LP implant is feasible and safe after removal of infected CIED with cumulative adverse events at 4% and a reinfection rate of 0.4%. Large prospective studies are needed to better evaluate the best timing of LP implantation after TLR of an infected CIED.

Chinese emergency expert consensus on bedside temporary cardiac pacing (2023)

Temporary cardiac pacing is an essential technique in the diagnosis and treatment of arrhythmias. Due to its urgency, complexity, and uncertainty, it is necessary to develop an evidence-based emergency operation norms. Currently, there is no specific consensus guidelines at home or abroad. The Emergency Branch of Chinese Medical Association organized relevant experts to draft the Chinese emergency expert consensus on bedside temporary cardiac pacing (2023) to guide the operation and application of bedside cardiac pacing. The formulation of the consensus adopts the consensus meeting method and the evidentiary basis and recommendation grading of the Oxford Center for Evidence-based Medicine in the United States. A total of 13 recommendations were extracted from the discussion on the methods of bedside temporary cardiac pacing, the puncture site of transvenous temporary cardiac pacing, the selection of leads, the placement and placement of leads, pacemaker parameter settings, indications, complications and postoperative management. The recommended consensus includes the choice between transcutaneous and transvenous pacing, preferred venous access for temporary transvenous pacing, the target and best guidance method for implantation of bedside pacing electrodes, recommended default pacemaker settings, recommended indications for sinoatrial node dysfunction, atrioventricular block, acute myocardial infarction, cardiac arrest, ventricular and supraventricular arrhythmias. They also recommended ultrasound guidance and a shortened temporary pacing support time to reduce complications of temporary transvenous cardiac pacing, recommended bedrest, and anticoagulation after temporary transvenous pacing. Bedside temporary cardiac pacing is generally safe and effective. Accurate assessment, correct selection of the pacing mode, and timely performance of bedside temporary cardiac pacing can further improve the survival rate and prognosis of related emergency patients.

Temporary Transvenous Pacing Over Three Years at a Regional Australian Hospital

Temporary Transvenous Pacing Over Three Years at a Regional Australian Hospital

Cardiac Perforation by Temporary Transvenous Pacing Wires (TPW): Incidence and Risk Factors

Cardiac Perforation by Temporary Transvenous Pacing Wires (TPW): Incidence and Risk Factors

Rate of various access sites for temporary transvenous pacing and different outcomes at Lady Reading Hospital, Peshawar Pakistan.

To evaluate the various temporary transvenous pacemaker (TPM) access sites, its indications, procedural complications, and outcomes of patients. This prospective study conducted in a tertiary care hospital of Peshawar, included 100 patients, who underwent TPM for any reasons, via the trans jugular, subclavian, or trans-femoral route. The duration of the study was from October 1st, 2021 to March 31st, 2022. The demographic, procedure -related complications, causes of complete heart block and in hospital outcomes were recorded. Of the 100 patients who underwent temporary transvenous pacing, 56%were males and 44% were females, with an age range of 46-80 years. In majority of the patients, (N =54) internal jugular vein was used as the venous access site followed by the subclavian vein. (N=24). Coronary artery disease was prevalent in 42% of the patients. 50% had complete AV block, 19% had symptomatic second-degree block, and 10% had sinus nodal diseases. Seventy three percent of the patients needed TPM implantation on an emergency basis, which is statistically significant (p=0.009). Almost 40% of the patient ultimately underwent a permanent pacemaker. Out of 100 patients, 16 patients expired. The major procedure related complications were bleeding 16% overall at the puncture site and 14.8% in the internal jugular group. Other complications were local infection 13% at the insertion site followed by hemopericardium 3%, in the internal jugular group. Atrioventricular block is the commonest indication for temporary pacing in our study. The average time the TPM remained in place was significantly higher in the trans jugular approach group along with a higher complication rate in this group.

Reducing cardiac tamponade caused by temporary pacemaker perforation in transcatheter aortic valve replacement

BackgroundCardiac tamponade caused by temporary right ventricular (RV) pacemaker perforation is a rare but serious complication in transcatheter aortic valve replacement (TAVR). AimsTo study the incidence of temporary pacemaker related cardiac tamponade in TAVR, and the relation to the type of pacemaker lead used in periprocedural temporary transvenous pacing. MethodsA single center registry of transfemoral TAVRs in 2014–2020. Main inclusion criterion was peri-operative use of a temporary RV pacing lead. Main exclusion criteria were a preoperatively implanted permanent pacemaker or the exclusive use of left ventricular guidewire pacing. Incident cardiac tamponade was classified as pacemaker lead related, or other. Patients were grouped according to type of temporary RV pacing wire. Results810 patients were included (age 80.5 ± 7.3 [mean ± standard deviation], female 319, 39.4%). Of these, 566 (69.9%) received a standard RV temporary pacing wire (RV-TPW), and 244 (30.1%) received temporary RV pacing through a permanent, passive pacemaker lead (RV-TPPL). In total, 18 (2.2%) events of cardiac tamponade occurred, 12 (67%) were pacemaker lead related. All pacemaker lead-related cardiac tamponades occurred in the group who received a standard RV-TPW and none in the group who received RV-TPPL (n = 12 [2.1%] vs. n = 0 [0%], p = 0.022). No difference in cardiac tamponade due to other causes was seen between the groups (p = 0.82). ConclusionsThe use of soft-tip RV-TPPL was associated with a lower risk of pacemaker related cardiac tamponade in TAVR. When perioperative pacing is indicated, temporary RV-TPPL may contribute to a significant reduction of cardiac tamponade in TAVR.

Simulation-based Mastery Learning Improves Emergency Medicine Residents' Ability to Perform Temporary Transvenous Cardiac Pacing.

Temporary transvenous cardiac pacing (TVP) is a critical intervention that emergency physicians perform infrequently in clinical practice. Prior simulation studies revealed that emergency medicine (EM) residents and board-certified emergency physicians perform TVP poorly during checklist-based assessments. Our objective in this report was to describe the design and implementation of a simulation-based mastery learning (SBML) curriculum and evaluate its impact on EM residents' ability to perform TVP. An expert panel of emergency physicians and cardiologists set a minimum passing standard (MPS) for a previously developed 30-item TVP checklist using the Mastery Angoff approach. Emergency medicine residents were assessed using this checklist and a high-fidelity TVP task trainer. Residents who did not meet the MPS during baseline testing viewed a procedure video and completed a 30-minute individual deliberate practice session before retesting. Residents who did not meet the MPS during initial post-testing completed additional deliberate practice and assessment until meeting or exceeding the MPS. The expert panel set an MPS of correctly performing 28 (93.3%) checklist items. Fifty-seven EM residents participated. Mean checklist scores improved from 13.4 (95% CI 11.8-15.0) during baseline testing to 27.5 (95% CI 26.9-28.1) during initial post-testing (P < 0.01). No residents met the MPS at baseline testing. The 21 (36.8%) residents who did not meet the MPS during initial post-testing all met or exceeded the MPS after completing one additional 30-minute deliberate practice session. Emergency medicine residents demonstrated significantly improved TVP performance with reduced variability in checklist scores after completing a simulation-based mastery learning curriculum.

126: A CASE REPORT OF ELECTRICAL STORM POST-COVID-19 VACCINATION

Introduction: Post-vaccination arrhythmia is reported as a possible cardiovascular side effect of COVID-19 vaccination. We present a case of ventricular tachycardia (VT) storm in a young healthy man following the 2nd dose of COVID-19 vaccination in the absence of underlying structural heart disease, myocarditis or arrhythmic syndromes. Description: A 38-year-old male with no medical history was admitted after an out-of-hospital cardiac arrest and found to be in VT storm within 24 hours of receiving his 2nd dose of COVID-19 vaccination. He received 4 shocks en route and had another episode of pulseless VT on arrival where Amiodarone was initiated. Laboratory values showed elevated inflammatory markers, and COVID tests were negative. Troponin peaked at 1.5 ng/ml. Initial transthoracic echocardiogram (TTE) revealed normal left ventricular ejection fraction (LVEF) without regional wall motion abnormality. On Day 2, he developed VT storm and was given magnesium sulfate, lidocaine and an additional bolus of amiodarone. Repeat TTE revealed a significant decrease in EF. He became hypotensive requiring inotropes and was emergently taken to the cath lab where intra-aortic balloon pump (IABP) and temporary transvenous pacing (TVP) were placed. Cardiac catheterization revealed normal coronary arteries, elevated left ventricular end diastolic pressure and mildly dilated LV with global hypokinesis and EF of 30%. His condition slowly improved without further occurrences of VT storm. Follow up TTE revealed normal LVEF, IABP and TVP were removed, and he was extubated. Cardiovascular magnetic resonance imaging showed no evidence of myocarditis with normal LV size. An automatic implantable cardioverter-defibrillator was placed. Genetic testing for Brugada syndrome was negative. Discussion: VT storm typically occurs with underlying structural heart disease, inherited arrhythmic syndromes or myocarditis, and is often difficult to identify a specific trigger. Although this is the first case report of VT storm occurring after the COVID-19 vaccine, it is important to note that the lack of a definitive test to diagnose myocarditis such as biopsy is a major limiting factor. This case report also supports the need for structured studies regarding a possible relationship between VT storm and COVID-19 vaccination.

Outcome of emergency transvenous cardiac pacing placement by echocardiography guidance in non-cardiac centre

Temporary transvenous cardiac pacing (TTVCP) is crucial and lifesaving procedure for hemodynamically unstable bradyarrhythmia. TTVCP placement under fluoroscopy guidance is considered the “gold-standard”. However, its use is limited by equipment availability. During the COVID-19 pandemic, access to operation-theatre with fluoroscopy service is severely restricted due to delay in confirming patient COVID-19 status (COVID19 PCR 6 h, GeneXpert 2 h). With this limitation, physicians rely on echocardiography guided placement of TTVCP for unstable emergent cases.

Inflammatory infiltration of the cardiac conduction system in acute lymphocytic myocarditis.

A 53-year-old man with prior history of bone marrow transplant after acute myeloblastic leukaemia was admitted in the acute cardiac care unit due to suspected acute myocarditis. At admission, his electrocardiogram (ECG) showed right bundle branch block and left anterior fascicular block (Panel A). Previously, he had been assessed regularly in a dedicated cardio-oncology clinic, with normal ECG and transthoracic echocardiography (see Supplementary material online, Videos S1 and S2). Despite high-dose pulses of methylprednisolone, he developed both complete atrio-ventricular (AV) block and progressive left ventricular systolic dysfunction (see Supplementary material online, Videos S3 and S4), leading to cardiogenic shock requiring temporary transvenous pacing and mechanical circulatory support with VA-ECMO. However, he died on day 9 due to multiorgan failure. Gross examination of the heart (Panel B) was normal, but histopathology and immunohistochemistry showed significant infiltration of the ventricular myocardium (Panel C), AV node (Panel D) left anterior fascicle (Panel E), and right bundle branch (Panel F) by mononuclear CD3 + T cells, consistent with the diagnosis of lymphocytic myocarditis. High-definition images S1-S8 are included in the Supplementary material online.

Bedside temporary transvenous cardiac pacing lead placement in patients with tricuspid valve surgery without guidance of X‐ray: A single‐center experience

It is difficult to insert cardiac pacing leads in patient with tricuspid valve surgery (TVS). The aim of this study was to evaluate safety and effectiveness of a novel technique applied for bedside temporary pacemaker placement (TPP) in patients with TVS. We investigated patients with TVS who required bedside TPP without X-ray guidance in cardiac intensive care unit between January 2019 and March 2022. They were divided into Novel pre-shaped group (N=21) and Control group (routine pre-shaped group, N=26). The ordinary bipolar electrodes were applied in both groups. In Novel pre-shaped group, electrodes were reshaped by a novel technique with three-curve with anterior tip method, while electrodes were shaped by traditional strategy in Control group. We evaluated the operation duration, first-attempt success rate of the lead placement, pacing threshold, success rate of lead placement, the rate of leads displacement, and complications. Compared with that in Control group, the procedure time was significantly shortened and the first-attempt success rate of lead placement was obviously increased in Novel pre-shaped group (both p < 0.05). Although there was a slight reduction in complications in Novel pre-shaped group when compared with that in Control group. However, there were no statistical significance in pacing threshold, the success rate of lead placement, the rate of leads displacement, and complications when compared between two groups. We propose a novel technique, three-curve with anterior tip method, is a feasible and effective bedside method to insert emergency temporary pacing leads in patients with TVS.

Magnetic resonance imaging in patients with temporary external pacemakers.

To describe safety and feasibility of magnetic resonance imaging (MRI) in patients with transvenous temporary external pacemakers and whether artefacts affect the diagnostic image quality during cardiac MRI. We reviewed records of all patients treated with temporary external pacing between 2016 and 2020 at a tertiary centre. Temporary pacing was established using a transvenous standard active fixation pacing lead inserted percutaneously and connected to a MRI-conditional pacemaker taped to the skin. All patients undergoing cardiac or non-cardiac MRI during temporary transvenous pacing were identified. Before MRI, devices were programmed according to guidelines for permanent pacemakers, and patients were monitored with continuous electrocardiogram during MRI. Of 827 consecutive patients receiving a temporary external pacemaker, a total of 44 (5%) patients underwent MRI (mean age 71 years, 13 [30%] females). Cardiac MRI was performed in 22 (50%) patients, while MRI of cerebrum, spine, and other regions was performed in the remaining patients. Median time from implantation of the temporary device to MRI was 6 (3-11) days. During MRI, we observed no device-related malfunction or arrhythmia. Nor did we detect any change in lead sensing, impedance, or pacing threshold. We observed no artefacts from the lead or pacemaker compromising the diagnostic image quality of cardiac MRI. MRI provided information to guide the clinical management in all cases. MRI is feasible and safe in patients with temporary external pacing established with a regular MRI-conditional pacemaker and a standard active fixation lead. No artefacts compromised the diagnostic image quality.

The association of racial differences with in-hospital outcomes of patients admitted for sinus node dysfunction.

BackgroundThe impact of race and its related social determinants of health on cardiovascular disease outcomes has been well documented. However, limited data exist regarding the association of race with in-hospital outcomes in patients admitted for sinus node dysfunction (SND).ObjectiveTo evaluate whether racial disparities exist in outcomes for patients hospitalized with a primary diagnosis of SND.MethodsThe National Inpatient Sample was queried from 2011 to 2018 for relevant ICD-9 and ICD-10 diagnosis and procedure codes. Baseline characteristics and in-hospital outcomes in patients with a primary diagnosis of SND were compared among White and non-White patients. A multivariate logistic regression model was used to adjust for potential confounding factors and statistically significant comorbidities between both cohorts.ResultsWe identified 655,139 persons admitted with a primary diagnosis of SND, 520,926 (79.5%) of whom were White. Non-White patients had significantly higher all-cause mortality, length of stay, and total hospital cost. There were lower odds of pacemaker insertion (adjusted odds ratio [aOR] 1.13 [95% confidence interval (CI) 1.11–1.15]), temporary transvenous pacing (aOR 1.15 [95% CI 1.11–1.22]), and cardioversion (aOR 1.50 [95% CI 1.42–1.58]) in non-White patients. A subgroup analysis was performed and non-Hispanic Black race was predictive of a decreased odds of pacemaker insertion, cardioversion/defibrillation, and temporary transvenous pacing.ConclusionSignificant differences of in-hospital outcomes exist between White and non-White patients with SND. These findings appeared to be primarily driven by disparities in non-Hispanic Black patients. Increased recognition and focused efforts to mitigate these disparities will improve the care of underrepresented populations treated for SND.

Rate of permanent cardiac implantable electronic device infections after active fixation temporary transvenous pacing: A nationwide Danish cohort study.

BackgroundTemporary transvenous pacing (TP) has been associated with an increased risk of cardiac implantable electronic device (CIED) infections, but there is little data to document this in contemporary populations.ObjectiveTo investigate the impact of active fixation TP on rate of CIED infections in a nationwide cohort of Danish patients.MethodsWe identified all patients who underwent a first-time CIED implantation between 2009 and 2017. Patients were categorized according to TP status at implantation and followed for 1 year. The primary outcome was local or systemic CIED infection resulting in device system removal. The secondary outcomes were systemic CIED infections and hospitalization for infective endocarditis (IE).ResultsWe included a total of 40,601 CIED patients. A total of 2952 were treated with active fixation TP. The primary outcome was met in 246 patients. Risk of CIED infection at 1 year was 0.61% for patients not treated with TP and 0.65% for patients who were, HR of 1.28 (95% CI 0.80–2.05) and adjusted HR 0.85 (95% CI 0.51–1.42). More systemic CIED infections and IE hospitalizations occurred in TP patients; however, these differences did not persist after confounder adjustment. Cumulative mortality at 1 year was 16.8% in patients with TP vs 8.4% in patients without.ConclusionActive fixation TP was not associated with a higher rate of CIED infections. Patients treated with TP had higher mortality, more systemic CIED infections, and more IE hospitalizations within first year of implantation. Most was attributable to an accumulation of risk factors for infection among TP patients.

S2653 Candida Liver Abscesses Due to a Penetrating Duodenal Ulcer

Introduction: Fungal infections of the liver commonly occur in patients with neutropenia, hematologic malignancies, and chemotherapy. The most common isolated agents are species of the Candida family, originating from the translocation of the gastrointestinal tract to the liver. Here, we present a rare case of multiple fungal abscesses in an immunocompetent host due to a perforating duodenal ulcer. Case Description/Methods: A 59-year-old man with COPD, hypertension, peptic ulcer disease, and obesity presented for altered mental status and fever. He was found to have right lower lobe pneumonia and complete heart block treated with antibiotics, temporary transvenous pacing then leadless permanent pacemaker. During his stay, he presented with melena. He underwent an upper endoscopy that showed a large 40 mm nonbleeding cratered duodenal ulcer with possible perforation and a superficial gastric ulcer with a flat pigmented spot. A CT scan of the abdomen and pelvis showed 3 perihepatic fluid collections along the left lobe, right lobe, and gallbladder fossa with the largest measuring 9cmx1.5cmx9cm and associated pneumobilia. There was no intra-abdominal free air. The patient was clinically stable, afebrile, and denied significant abdominal pain. There were no signs of peritoneal irritation on the physical exam. He did have a persistent neutrophilic leukocytosis with a white cell count of 18,400/ml, Hemoglobin 9g/dl, total bilirubin 0.6 mg/dl, AST 29 IU/l, ALT 38 IU/l, Alkaline phosphatase 53IU/L. The patient was managed conservatively with broad-spectrum antibiotics and proton pump inhibitors. He underwent urgent percutaneous drainage of the 2 largest abscesses. Cultures from the collections grew Candida albicans only. Blood cultures were negative. Thus, the patient was treated with micafungin then transitioned to fluconazole for a 6-week course of therapy. Amoebic and Echinococcus antibodies, and HIV tests were negative. A follow-up CT showed resolution of the liver collections. Discussion: This is a rare case of candida liver abscesses as a complication of a penetrating large duodenal ulcer successfully treated with conservative management. Pyogenic liver abscesses are unusual presentations of perforated gastroduodenal ulcers. In addition to the drainage of the collections, antifungal agents should be considered in the initial antimicrobial regimen choice even in immunocompetent hosts.Figure 1.: From A to C: CT demonstrated liver abscesses (frontal and axial views); D: Upper endoscopy showing a cratered duodenal ulcer.

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Management of patients explanted for implantable cardioverter defibrillator infections: Bridge therapy with external temporary ICD.

In case of cardiacimplantable electronicdevice (CIED)-related infections, it is mandatory to completely remove the device and administer prolonged antibiotic therapy. The management of patients explanted for an implantable defibrillator (ICD) infection is complex especially in patients needing anti-bradycardia pacing or tachyarrhythmia protection. We tested the efficacy and safety of a conventional ICD externally connected to a transvenous dual-coil lead as bridging therapy before the reimplant, comparing outcomes with a historical cohort of patients (N=113) treated with temporary transvenous pacing. We enrolled 18 patients explanted for ICD infection and needing prolonged antibiotic therapy in three high-volume Italian centers. They received an external ICD stand-by for a mean of 16.5 (4-30) days before the reimplant. No patient experienced malfunction of the system, with a significant reduction of this complication versus temporary transfemoral pacing (37%, p=.004). Post-procedural occurrence of other complications (infection, relevant local bleeding, ventricular tachycardia during insertion of the lead, cardiac perforation, and venous thromboembolism) was low and not different in the two groups. One patient experienced an electrical storm, effectively recognized by the external ICD and treated with anti-tachycardia pacings (ATPs) and shocks. An approach with an external ICD seems to be a safe and viable option as bridging therapy in patients requiring ICD explant for CIED infection.