Reimplantation and long-term mortality after transvenous lead extraction in a high-risk, single-center cohort

Abstract

Purpose The use of cardiac implantable electronic devices (CIEDs) has increased significantly over the last decades. With the development of transvenous lead extraction (TLE), procedural success rates also improved; however, data regarding long-term outcomes are still limited. The aim of our study was to analyze the outcomes after TLE, including reimplantation data, all-cause and cause-specific mortality. Methods Data from consecutive patients undergoing TLE in our institution between 2012 and 2020 were retrospectively analyzed. Periprocedural, 30-day, long-term, and cause-specific mortalities were calculated. We examined the original and the revised CIED indications and survival rate of patients with or without reimplantation. Results A total of 150 patients (age 66 ± 14 years) with 308 leads (dwelling time 7.8 ± 6.3 years) underwent TLE due to pocket infection (n = 105, 70%), endocarditis (n = 35, 23%), or non-infectious indications (n = 10, 7%). All-cause mortality data were available for all patients, detailed reimplantation data in 98 cases. Procedural death rate was 2% (n = 3), 30-day mortality rate 2.6% (n = 4). During the 3.5 ± 2.4 years of follow-up, 44 patients died. Arrhythmia, as the direct cause of death, was absent. Cardiovascular cause was responsible for mortality in 25%. There was no significant survival difference between groups with or without reimplantation (p = 0.136). Conclusions Despite the high number of pocket and systemic infection and long dwelling times in our cohort, the short-and longterm mortality after TLE proved to be favorable. Moreover, survival without a new device was not worse compared to patients who underwent a reimplantation procedure. Our study underlines the importance of individual reassessment of the original CIED indication, to avoid unnecessary reimplantation.

Implantable loop recorder as a strategy following cardiovascular implantable electronic device extraction without reimplantation

“…Among this group, symptomatic bradyarrhythmias, excluding second‐ and third‐degree AV block, were the predominate indications for the initial implant. A large proportion were also thought to have a device implanted without clear indication (23.5%), an issue that has been noted in several other studies and mirrored in our own cohort 10,12,13 . Long‐term outcomes among those with no device reimplantation are limited by heterogenous cohorts with disparate outcomes.…”

“…CIEDs are implanted with the intention for lifelong treatment, prevention, and monitoring; however, with CIED infections on the rise, percutaneous transvenous lead extraction (TLE) is becoming more frequent 8,9 . Most risk factors for CIED infection are largely nonmodifiable, therefore the decision for reimplantation must be carefully considered as reinfection and the morbidity of reextraction is considered higher in this population 10,11 …”

“…8,9 Most risk factors for CIED infection are largely nonmodifiable, therefore the decision for reimplantation must be carefully considered as reinfection and the morbidity of reextraction is considered higher in this population. 10,11 In certain clinical scenarios, such as high-grade atrioventricular (AV) block, severe ventricular arrhythmias, or high pacing needs, the decision for reimplantation is straight forward; however, in the absence of these indications, the decision for reimplantation may be unclear and risk of future event is difficult to predict. As no consistent guidelines exist for the monitoring of patients undergoing TLE without planned subsequent device reimplant, next steps are often guided by shared decision making between the patient and clinician, resulting in significant variability in clinical practice.…”

Antibiotic-Eluting Envelopes for the Prevention of Cardiac Implantable Electronic Device Infections: Rationale, Efficacy, and Cost-Effectiveness

“…A study by Lee et al reported 7.2% in-hospital mortality and 25.3% mortality at 1 year ( 3 ) among 387 patients following lead extraction for CIED infection. In contrast, more recent retrospective data from a single center study demonstrate lower 30-day mortality rates following transvenous lead extraction (due to CIED infection in 93% of the studied population) ( 14 ). The trend for increased mortality despite successful infection eradication was preserved at 3 years as reported by Sohail et al ( 10 ).…”

Predictors of long-term mortality after transvenous lead extraction of an infected cardiac device: a risk prediction model for sustainable care delivery.

“…Nonetheless, literature about the long-term follow-up of patients undergoing TLE is still lacking. In particular, short-term safety and efficacy of TLE have been extensively investigated (2,6,7), while reports on very long-term outcomes after TLE are still limited and particularly focused on infection-related predictors of mortality (8)(9)(10)(11)(12)(13)(14)(15). Moreover, there is evidence in the scientific literature of substantial costs associated with extraction and reimplantion procedures (16).…”