title: Influence of vegetation size on the clinical presentation and outcome of lead-associated endocarditis: results from the MEDIC registry.
abstract: OBJECTIVE
  The purpose of this study was to determine whether the clinical presentation of lead-associated endocarditis (LAE) is related to the size of lead vegetations and how size is related to bacteriology and clinical outcomes.
  
  
  BACKGROUND
  Cardiac implantable electronic device (CIED) infection may present as either local pocket infection or bloodstream infection with or without LAE. LAE is associated with significant morbidity and mortality.
  
  
  METHODS
  The clinical presentation and course of LAE were evaluated by the MEDIC (Multicenter Electrophysiologic Device Cohort) registry, an international registry enrolling patients with CIED infection. Consecutive LAE patients enrolled in the MEDIC registry between January 1, 2009 and December 31, 2012 were analyzed. The clinical features and outcomes of 2 groups of patients were compared based on the size of the lead vegetation detected by echocardiography (> or <1 cm in diameter).
  
  
  RESULTS
  There were 129 patients with LAE enrolled into the MEDIC registry. Of these, 61 patients had a vegetation <1 cm in diameter (Group I) whereas 68 patients had a vegetation ≥1 cm in diameter (Group II). Patients in Group I more often presented with signs of local pocket infection, whereas Group II patients presented with clinical evidence of systemic infection. Staphylococcus aureus was the organism most often responsible for LAE, whereas infection with coagulase-negative staphylococci was associated with larger vegetations. Outcomes were improved among those who underwent complete device removal. However, major complications were associated with an open surgical approach for device removal.
  
  
  CONCLUSIONS
  The clinical presentation of LAE is influenced by the size of the lead vegetation. Prompt recognition and management of LAE depends on obtaining blood cultures and echocardiography, including transesophageal echocardiography, in CIED patients who present with either signs of local pocket or systemic infection.
authors.affiliation: Department of Medicine, Division of Cardiology, Cardiac Electrophysiology Laboratory, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania. Electronic address: arnold.greenspon@jefferson.edu.
authors.forename: Arnold J
authors.initials: AJ
authors.lastname: Greenspon
authors.affiliation: Department of Medicine, Division of Infectious Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota.
authors.forename: Katherine Y
authors.initials: KY
authors.lastname: Le
authors.affiliation: Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington.
authors.forename: Jordan M
authors.initials: JM
authors.lastname: Prutkin
authors.affiliation: Department of Medicine, Division of Infectious Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota.
authors.forename: M Rizwan
authors.initials: MR
authors.lastname: Sohail
authors.affiliation: Department of Medicine, Division of Infectious Diseases, Mayo Clinic, Phoenix, Arizona.
authors.forename: Holenarasipur R
authors.initials: HR
authors.lastname: Vikram
authors.affiliation: Department of Medicine, Division of Infectious Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota.
authors.forename: Larry M
authors.initials: LM
authors.lastname: Baddour
authors.affiliation: Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Stephan B
authors.initials: SB
authors.lastname: Danik
authors.affiliation: Department of Medicine, Division of Infectious Diseases, Wake Forest University, Winston-Salem, North Carolina.
authors.forename: James
authors.initials: J
authors.lastname: Peacock
authors.affiliation: Department of Medicine, Division of Infectious Diseases, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain.
authors.forename: Carlos
authors.initials: C
authors.lastname: Falces
authors.affiliation: Department of Medicine, Division of Infectious Diseases, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain.
authors.forename: Jose M
authors.initials: JM
authors.lastname: Miro
authors.affiliation: Department of Medicine, Division of Cardiology, Elisabeth Krankenhaus, Essen, Germany.
authors.forename: Christoph
authors.initials: C
authors.lastname: Naber
authors.affiliation: Department of Surgery, Division of Cardiothoracic Surgery, University of Miami, Miami, Florida.
authors.forename: Roger G
authors.initials: RG
authors.lastname: Carrillo
authors.affiliation: Department of General Internal Medicine and Health Services, University of California-Los Angeles, Los Angeles, California.
authors.forename: Chi-Hong
authors.initials: CH
authors.lastname: Tseng
authors.affiliation: Department of Medicine, Division of Infectious Diseases, University of California-Los Angeles, Los Angeles, California.
authors.forename: Daniel Z
authors.initials: DZ
authors.lastname: Uslan
mesh_terms: D000368:Aged; D017147:Defibrillators, Implantable / Q000009:adverse effects / Q000382:microbiology*; D004567:Electrodes, Implanted / Q000382:microbiology*; D004697:Endocarditis, Bacterial / Q000382:microbiology*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D010138:Pacemaker, Artificial / Q000009:adverse effects / Q000382:microbiology*; D016459:Prosthesis-Related Infections / Q000382:microbiology* / Q000628:therapy; D012042:Registries
keywords: endocarditis; implantable cardioverter-defibrillator; permanent pacemaker