Kardiyak cihaz cebi enfeksiyonu ve elektrot ilişkili tromboz

Özet

Kardiyak cihaz cebi çevresinde ağrı, kızarıklık veya akıntı ile başvuran hastada BT, enfeksiyonun derin cebe ve komşu toraks yapılarına yayılımını haritalayabilir. Kontrastlı toraks incelemesi cepteki sıvı koleksiyonunu, çevre yağ dokusu reaksiyonunu ve mediastinal uzanımı gösterirken venöz faz/BT venografi elektrot çevresindeki santral ven trombozunu ortaya koyar. Tek başına görüntüleme erken enfeksiyonu doğrulayamaz; yakın tarihli işlem sonrası hematom ve beklenen doku değişiklikleri benzer görünebilir. Atlanan venöz tıkanıklık kollateral oluşumu ve vena kava superior sendromuna, enfeksiyon ise mediastinit veya sistemik yayılıma yol açabilir.

Faz ve pencere

Venöz tanısal

Kontrastlı BT'de jeneratör cebindeki lokalize sıvı koleksiyonlar, özellikle halka biçimli kontrastlanma ve gaz kabarcıkları enfeksiyonu işaret edebilir; ayrıca FDG PET/CT, şüpheli olgularda iğne aspirasyonuna alternatif olarak yüksek duyarlılık ve özgüllük sunabilir.

Venöz tanısal

Üst ekstremite veya santral venöz kontrast zamanlamalı incelemede subklavyen, brakiyosefalik ven ve vena kava superior lümenindeki dolum defekti, darlık ve kollateral yollar değerlendirilir.

Önerilen pencereler: Mediasten (G 350 / M 50), Yumuşak doku (G 400 / M 40), Anjiyo (G 600 / M 150).

BT bulguları

• Jeneratör çevresinde basit sıvıdan farklı olarak kalınlaşmış duvarlı veya çevresel kontrastlanan koleksiyon
• Cep içi gaz, cilt fistül yolu veya cilt altı dokulara açılan koleksiyon
• Jeneratör ve elektrot güzergâhı çevresinde yağ planlarının silinmesi ve yumuşak doku kalınlaşması
• Elektrotu çevreleyen santral ven lümeninde kontrastla dolmayan trombüs veya segmental oklüzyon
• Brakiyosefalik ven ya da vena kava superior darlığına eşlik eden azigos, hemiazigos ve göğüs duvarı kollateralleri
• Cep enfeksiyonu, fistül traktı veya medüller sıvı koleksiyonu ile birlikte mediastinite veya sistemik belirtilere yol açabilir; bu durum komplikasyon sınıflamasında 'complicated' kategorisini oluşturur.
• Sağ atriyum veya ventrikülde elektrot çevresinde izlenen dolum defekti; BT bu bulguyu vejetasyon ile trombüs arasında kesin biçimde ayırt edemez.

Normalde

İmplantasyondan sonraki ilk aylarda normal BT değişiklikleri enfeksiyon bulgularına benzeyebilir. BT, cihaz enfeksiyonlarında yüzeyel ve derin tutulumları değerlendirmeye yardımcı olabilir.

Ayırıcı tanı

Postoperatif cep hematomu

yeni işlem sonrasında olabilir; yoğun içerik ve kontrastsız yüksek dansite görülebilir, belirgin duvar kontrastlanması veya yaygın inflamasyon beklenmez.

Yüzeysel selülit

cilt ve subkutan dokuda yaygın ödem vardır, fakat jeneratör cebinde derin koleksiyon bulunmaz.

Sadece venöz stenoz

damar çevresindeki elektrotlara eşlik eden dar lümen ve kollateral akım vardır; cepte apse veya inflamasyon yoktur.

Sağ kalpte vejetasyon

cihaz elektrodu boyunca kitle veya dolum defekti olarak görünebilir; BT tek başına trombüs ile güvenilir biçimde ayırt edemez ve ekokardiyografi sınırlamaları nedeniyle FDG PET/CT daha güvenilir olabilir.

Tuzaklar

• İmplantasyon veya jeneratör değişiminden kısa süre sonra cepte sıvı ve hafif yağ bulanıklığı steril iyileşme/hematomla ilişkili olabilir; eski görüntü ve klinik zamanlamayı kullan.
• Sağ kalpte elektrot çevresi kontrast karışım artefaktı trombüs taklidi yapabilir; gecikmiş dolum veya farklı düzlemde kalıcılığını kontrol et.
• Elektrot güzergâhında görülen intrakardiyak kitle veya dolum defekti BT'de kesin olarak vejetasyon olarak adlandırılamaz; kitle enfeksiyon kaynaklı olmayan trombüs de olabilir.

Kendini dene

1. Yakın zamanda cihaz değişimi yapılan hastada jeneratör çevresinde yüksek dansiteli sıvı var, belirgin duvar kontrastlanması yok. En olası açıklama nedir?

   • Postoperatif hematom
   • Cep apsesi
   • Lenfoma
   • Perikard kisti
   Cevabı göster

   Postoperatif hematom. Erken işlem sonrası yüksek dansiteli cep içeriği hematomla uyumludur; apse daha çok duvar kontrastlanması ve çevresel inflamasyonla desteklenir.

2. Vena kava superiorda elektrotların çevresinde daralma, dolum defekti ve göğüs duvarı kollateralleri izleniyor. Hangi süreç ön plandadır?

   • Elektrot ilişkili venöz obstrüksiyon
   • Pulmoner arter hipertansiyonu
   • Aort koarktasyonu
   • Sol atriyal miksoma
   Cevabı göster

   Elektrot ilişkili venöz obstrüksiyon. Santral ven lümenindeki darlık/dolum defekti ve kollateral ağ elektrot ilişkili tromboz veya stenozu düşündürür; diğer seçenekler venöz bulguları açıklamaz.

İlgili konular

• Kalp pili/ICD elektrot malpozisyonu ve perforasyonu

Kaynaklar

Bu sayfadaki 33 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 9 cümle bu karşılaştırmada düzeltildi (2026-10-08).

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