Lead Extraction in Patients With Endocarditis and CIEDs

Apr 25, 2023
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Authors:
Sciria CT, Kogan EV, Mandler AG, et al.
Citation:
Low Utilization of Lead Extraction Among Patients With Infective Endocarditis and Implanted Cardiac Electronic Devices. J Am Coll Cardiol 2023;81:1714-1725.
Summary By:
Thomas C. Crawford, MD, FACC

Quick Takes

  • Only one of eight patients with CIEDs who are admitted for infective endocarditis underwent transvenous lead extraction/removal (TLE) in a nationwide hospital readmission sample of >25,000 patients.
  • Presence of Staphylococcus aureus infection, ICD, and large hospital size were independently associated with TLE.
  • Patients with older age, female sex, dementia, and kidney disease were less likely to undergo TLE.

Study Questions:

What is the utilization of transvenous lead removal/extraction (TLE) among hospital admissions with infective endocarditis?

Methods:

The authors examined 25,303 admissions for patients with cardiac implantable electronic devices (CIEDs) and endocarditis between 2016 and 2019 using the Nationwide Readmissions Database.

Results:

Among admissions for patients with CIEDs and endocarditis, 11.5% were managed with TLE. The proportion undergoing TLE increased significantly from 2016–2019 (7.6% vs. 14.9%, p for trend < 0.001). Procedural complications were identified in 2.7%. Index mortality was significantly lower among patients managed with TLE (6.0% vs. 9.5%, p < 0.001). Presence of Staphylococcus aureus infection, implantable cardioverter-defibrillator (ICD), and large hospital size were independently associated with TLE management. TLE management was less likely with older age, female sex, dementia, and kidney disease. After adjustment for comorbidities, TLE was independently associated with significantly lower odds of mortality (odds ratio [OR], 0.47; 95% confidence interval [CI], 0.37-0.60 by multivariable logistic regression and OR, 0.51; 95% CI, 0.40-0.66 by propensity score matching).

Conclusions:

Utilization of lead extraction among patients with CIEDs and endocarditis is low, even in the presence of low rates of procedural complications. Lead extraction management is associated with significantly lower mortality and its use has trended upward between 2016 and 2019. Barriers to TLE for patients with CIEDs and endocarditis require investigation.

Perspective:

Infective endocarditis has been a Class I indication for TLE in patients with CIEDs for a number of years. The analysis of the nationwide hospital readmission database of patients with endocarditis and CIEDs shows that only 12% of patients underwent TLE. It is well established that patients, who are only treated with antibiotics or whose TLE is delayed, experience increased infection relapse rates, worse health outcomes, and increased mortality. The current study specifically confirms that patients undergoing TLE have significantly lower all-cause mortality following TLE. The current study does not provide information on what is responsible for this shocking apparent inadequacy—whether it results from poor access to extractor physicians or comprehensive extraction centers, poor physician knowledge, or perceived risks of complications with extraction. This report serves as a call to action to get to the bottom of this tremendous gap in lost opportunity to provide guideline-informed care. Just incredible!

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Sleep Apnea

Keywords: Arrhythmias, Cardiac, Cardiac Surgical Procedures, Defibrillators, Implantable, Dementia, Device Removal, Electronics, Medical, Endocarditis, Endocarditis, Bacterial, Heart Failure, Kidney Diseases, Patient Readmission, Staphylococcus aureus


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