Infekcja związana z implantacją ICD – powikłanie, o którym musimy pamiętać

Grudzień 18, 2014  |  Udostępnij  | 

Wszczepialne kardiowertery-defibrylatory (ICD) są urządzeniami, które od lat mają swoje dobrze ugruntowane miejsce w wachlarzu leczenia inwazyjnego oferowanego przez współczesną kardiologię. Wskazania do implantacji ICD obejmują profilaktykę wtórną nagłego zatrzymania krążenia (NZK) – pacjenci po NZK w mechanizmie migotania komór, a także profilaktykę pierwotną – o wiele liczniejsza grupa osób z wysokim ryzykiem wystąpienia arytmii komorowej. Gwoli przypomnienia, podstawowym kryterium zaliczających chorych do tej drugiej grupy jest obniżona poniżej 35% frakcja wyrzutowa lewej komory, w połączeniu z klinicznymi objawami niewydolności serca w II lub III okresie hemodynamicznym według NYHA. Patrząc na te dość szerokie wskazania, nie można się dziwić, że liczba wykonywanych w Polsce zabiegów ciągle rośnie. Niestety wraz z nią rośnie także liczba diagnozowanych powikłań infekcyjnych związanych z implantacją urządzenia (CIED).
Problem ten występuje we wszystkich krajach, w których medycyna osiągnęła wysoki poziom rozwoju, stąd określenie, jakie czynniki wpływają na wzrost ryzyka CIED stało się wyzwaniem dla naukowców. W artykule[1], jaki niedawno ukazał się na łamach Circulation, badacze z Waszyngtonu przeanalizowali przypadki ponad 200 tys. pacjentów po implantacji ICD w latach 2006-2009, których dane były dostępne w systemie Medicare. Jako potwierdzenie wystąpienia powikłań infekcyjnych przyjęto rejestrację kodu odpowiadającego CIED lub infekcyjnemu zapaleniu wsierdzia w pierwszych 6 miesiącach po wszczepieniu kardiowertera-defibrylatora. Do badania włączono także chorych z ICD, u których w trakcie hospitalizacji diagnozowano sepsę, bakteriemię, zapalenie tkanki podskórnej lub gorączkę niewiadomego pochodzenia. Łącznie przeanalizowano dane niemal 201 tys. chorych, spośród których wymienione powyżej kryteria spełniło 3390 osób (1,7%). Większość powikłań notowano w ciągu pierwszego 1,5 miesiąca od daty zabiegu. Zgodnie z danymi z wcześniej przeprowadzonych badań, na wzrost ryzyka infekcji wpływały mnogie choroby współistniejące. Do zidentyfikowanych czynników ryzyka należały: ciężka niewydolność serca, migotanie przedsionków, choroba wieńcowa (zwłaszcza po przebytym zabiegu wszczepienia by-passów), stan po wszczepienia sztucznej zastawki, POChP, cukrzyca i niewydolność nerek (zwłaszcza z koniecznością dializoterapii). Potwierdzono także występowanie większego ryzyka zakażenia po zabiegu reimplantacji w porównaniu z wszczepieniem pierwszorazowym (1,9 vs 1,6%, p<0,001). Częstość powikłań infekcyjnych nie pozostała także bez związku z typem wszczepianego urządzenia – dla układów jednojamowych wynosiła ona 1,4%, dla dwujamowych 1,5%, ale dla układów z funkcją resynchronizacji już 2%. Większą ilość zakażeń notowano także w przypadku operatorów z mniejszym doświadczeniem i w ośrodkach nieakademickich. Czynnikiem najsilniej zwiększającym ryzyko były powikłania okołozabiegowe wymagające wczesnej repozycji elektrody lub rewizji loży urządzenia – odsetek powikłań infekcyjnych w takich przypadkach sięgał 5,4%. Jak można było oczekiwać wystąpienie CIED było związane z istotnym pogorszeniem rokowania. Śmiertelność w ciągu pierwszych 6 miesięcy od implantacji ICD/CRT-D wynosiła odpowiednio 6,5% w przypadku zabiegów niepowikłanych oraz aż 12%, gdy wystąpiły powikłania infekcyjne (p<0,001).

Jak wynika z przedstawionego badania infekcyjne zapalenie wsierdzia w związku z zabiegiem wszczepienia kardiowertera-defibrylatora nie należy do rzadkości i powinno być zawsze wkalkulowane w sumaryczne ryzyko procedury. Należy o nim pamiętać zwłaszcza w przypadku osób z wieloma obciążeniami oraz gdy planowana jest skomplikowana procedura (implantacja CRT-D) lub zabieg związany z ponownym otwarciem loży uprzednio założonego urządzenia.

1. Prutkin J.M. et al., Rates of and factors associated with infection in 200 909 Medicare implantable cardioverter-defibrillator implants: results from the national cardiovascular data registry. Circulation 2014 Sep 31;130(13):1037-43.


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