Transvenous Lead Extraction in Patients with Cardiac Implantable Device: The Impact of Systemic and Local Infection on Clinical Outcomes—An ESC-EHRA ELECTRa (European Lead Extraction Controlled) Registry Substudy

Abstract

Background: Infections of cardiac implantable devices (CIEDI) have poor outcomes despite improvement in lead extraction (TLE) procedures. Methods: To explore the influence of CIEDI on the outcomes of TLE and the differences between patients with systemic (Sy) vs. local (Lo) CIEDI, we performed a sub-analysis of the EORP ELECTRa (European Lead Extraction ConTRolled) Registry. Results: Among 3555 patients enrolled by 73 centers in 19 Countries, the indication for TLE was CIEDI in 1850: 1170 with Lo-CIEDI and 680 with Sy-CIEDI. Patients with CIEDI had a worse in-hospital prognosis in terms of major complications (3.57% vs. 1.71%; p = 0.0007) and mortality (2.27% vs. 0.49%; p < 0.0001). Sy-CIEDI was an independent predictor of in-hospital death (H.R. 2.14; 95%CI 1.06–4.33. p = 0.0345). Patients with Sy-CIEDI more frequently had an initial CIED implant and a higher prevalence of comorbidities, while subjects with Lo-CIEDI had a higher prevalence of previous CIED procedures. Time from signs of CIEDI and TLE was longer for Lo-CIEDI despite a shorter pre-TLE antibiotic treatment. Conclusions: Patients with CIEDI have a worse in-hospital prognosis after TLE, especially for patients with Sy-CIEDI. These results raise the suspicion that in a relevant group of patients CIEDI can be systemic from the beginning without progression from Lo-CIEDI. Future research is needed to characterize this subgroup of patients.

Incomplete Lead Removal During the Extraction Procedure: Predisposing Factors and Impact on Long-Term Survival in Infectious and Non-Infectious Cases: Analysis of 3741 Procedures

“…A considerable number of reports have been published on long-term survival following transvenous lead extraction [10,[20][21][22]25,[37][38][39][40][41][42][43][44]. Particularly unsatisfactory results have been reported in patients with CIED infections despite treatment in accordance with guideline recommendations [1][2][3], with mortality being 20% in the first year, 35% at 3 years and even 40-45% at five years [20,21,25,[41][42][43][44][45].…”

“…The main risk factors can be classified into several categories: patient-dependent factors (heart failure, AF, low EF) [20,37,41,45], comorbidity-dependent factors (diabetes, renal failure) [20,38,39,41,42], infection-dependent factors (any infection, systemic infection, valve endocarditis, vegetations, large vegetations, vegetation remnants after TLE, MRSA infection, thrombocytopenia, anaemia) [10,25,[37][38][39][40][41]43,45], CIED-related factors (any CRT infection, lead number, CRT-p infection) [37,[41][42][43] and extraction-related factors (removal of multiple leads, lack of clinical success, major and minor extraction complications, presence of ghosts after TLE, retained lead fragments) [20][21][22]39,[42][43][44].…”

Transvenous Lead Extraction Procedure—Indications, Methods, and Complications

“…The strongest indication for TLE is CIED infections [ 6 , 7 ]. CIED infections have become increasingly prevalent, due to the number of CIED implantation procedures and since these procedures are performed in an aging population with multiple comorbidities [ 8 , 9 ]. The multiplication of cardiac pacing centers where staff experience is inadequate can be another explanation [ 10 ].…”

Vacuum-Implemented Removal of Lead Vegetations in Cardiac Device-Related Infective Endocarditis

“…According to the most recent European Heart Rhythm Association (EHRA) guidelines [ 5 ], infected lead extraction is always recommended and a percutaneous approach is the first choice (TLE: transvenous lead extraction). Although the high rates of successful percutaneous removal, in-hospital mortality can reach 2.3%, especially when a systemic infection is suspected [ 6 ]. In these settings, as well as in large (>20 mm) vegetations, a vacuum-assisted aspiration of the mass or a conventional surgical approach is suggested [ 5 ].…”