Impact of delayed device re‐implantation on outcomes of patients with cardiovascular implantable electronic device related infective endocarditis

Abstract

Background Optimal timing of cardiovascular implantable electronic device (CIED) re‐implantation following device removal due to infection is undefined. Multinational guidelines reflect this and include no specific recommendation for this timing, while others have recommended waiting at least 14 days in cases of CIED related infective endocarditis (CIED‐IE). The current work seeks to clarify this issue. Methods We retrospectively reviewed institutional data at Mayo Clinic, Minnesota of patients aged ≥ 18 years who developed CIED‐IE from January 1, 1991 to February 1, 2016. CIED‐IE was defined as echocardiogram reported device lead or valvular vegetation. Regression analyses were used to relate the risk of clinical outcomes to the interval between CIED removal and re‐implantation and the location of vegetations. Results A total of 109 patients met study inclusion criteria. A majority (68.8%) of patients were men and the median age was 68.0 years. Transoesophageal echocardiogram (TEE) was performed in 95.4% of patients, with valve vegetations detected in 33.9% (n = 37). Survival analysis comparing patients in whom device re‐implantation was < 14 days vs. ≥14 days, and further categorized by those with and without valve vegetation, showed a significant difference (P = 0.028); patients with valve vegetation and reimplantation interval < 14 days had the lowest (58.7%) 12‐month survival. When adjusted for valve vegetation, longer time interval for reimplantation trended toward increased hospital length of stay (P = 0.079). Conclusion Our findings suggest that the recommended 14‐day delay between CIED extraction and re‐implantation in CIED‐IE patients is associated with a survival benefit, but longer length of hospital stay following re‐implantation.

Treatment and Prevention of Cardiovascular Implantable Electronic Device (CIED) Infections

“…d Blood cultures positive or no blood cultures performed prior to antibiotics e Treatment as for endocarditis 28,35,47 J o u r n a l P r e -p r o o f Timing considerations for new device implantation 28,35,50 a) blood cultures should be repeated after device removal and should be negative for at least 72 hours before new device placement.…”

“…The delay of at least 14 days has been associated with a survival benefit, particularly when a valve vegetation has been demonstrated. 50 c) new device implantation should be delayed until any other undrained site of infection has undergone adequate source control (e.g., psoas abscess). 35 J o u r n a l P r e -p r o o f • Avoid postoperative low-molecular-weight heparin bridging anticoagulant therapy where possible.…”

Update on Cardiovascular Implantable Electronic Device Infections and Their Prevention, Diagnosis, and Management: A Scientific Statement From the American Heart Association

“…Overall, the incidence of reinfection after device reimplantation is low. [48][49][50] In a recent systematic review and meta-analysis, the incidence rate of device reinfection for the pooled cohort was 0.45% per person per year. 48 In contrast, mortality rate associated with various device reimplantation strate-gies ranged from 3% to 11% in the included studies (with varying durations of follow-up).…”

Oral hygiene as a cardiovascular risk factor - review of the literature

“…IE is a disease caused by endocardial infection. The inflammatory process most often involves the valves, but it can also involve the atrial and ventricular endocardial surfaces or "foreign bodies in the heart," such as cardiostimulator leads [29,30,31,32,33]. IE can be caused by microorganisms such as bacteria, fungi, chlamydia, mycoplasmas.…”