Impact of timing of device removal on mortality in patients with cardiovascular implantable electronic device infections

Lead Extraction-Indications, Procedure, and Future Directions

Cardiac implantable electronic device (CIED) implantation has steadily increased in the United States owing to increased life expectancy, better access to health care, and the adoption of updated guidelines. Transvenous lead extraction (TLE) is an invasive technique for the removal of CIED devices, and the most common indications include device infections, lead failures, and venous occlusion. Although in-hospital and procedure-related deaths for patients undergoing TLE are low, the long-term mortality remains high with 10-year survival reported close to 50% after TLE. This is likely demonstrative of the increased burden of comorbidities with aging. There are guidelines provided by various professional societies, including the Heart Rhythm Society, regarding indications for lead extraction and management of these patients. In this paper, we will review the indications for CIED extraction, procedural considerations, and management of these patients based upon the latest guidelines.

Current trends and challenges in infective endocarditis

PURPOSE OF REVIEW

Infective endocarditis (IE) is a complex disease with increasing global incidence. This review explores recent trends in IE infection patterns, including healthcare-associated IE (HAIE), drug-use-associated IE (DUA-IE), multidrug-resistant organisms (MDROs), and challenges in managing prosthetic valve and device-related infections.

RECENT FINDINGS

Staphylococcus aureus has emerged as the leading cause of IE, especially in HAIE and DUA-IE cases. Increasingly prevalent MDROs, such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci, pose further clinical challenges. Advances in molecular diagnostics have improved the detection of culture-negative endocarditis. The introduction of the AngioVAC percutaneous aspiration device promises to change the management of right and possibly some left sided IE. Multidisciplinary team management and early surgery have demonstrated improved outcomes including partnerships with psychiatry and addictions services for those with intravenous DUA-IE.

SUMMARY

IE presents significant diagnostic and therapeutic challenges due to evolving infection patterns, MDROs, and HAIE. Early diagnosis using advanced imaging, appropriate early antimicrobial therapy, and multidisciplinary care, including timely surgery, are critical for optimizing patient outcomes.

Cardiac implantable electronic device infection

Cardiac implantable electronic device infections (CIEDI) are an important complication of device implantation associated with significant morbidity, mortality, and cost to the healthcare system. Identifying patients at high risk of device infection is paramount to improving decision making. This includes selecting appropriate devices and implementing adjunctive infection prevention measures, such as antimicrobial envelopes. In addition to meticulous antiseptic surgical technique, several other procedure-related practices can help reduce the risk of device infection. Developing expert centers with multidisciplinary teams capable of device extraction is important to manage patients with CIEDI. In this review, we aim to provide the reader with a succinct overview of CIEDI and summarize new evidence for risk assessment, prevention, diagnosis, and infection management.

State-of-the-Art Review: Complexities in Cardiac Implantable Electronic Device Infections: A Contemporary Practical Approach

Cardiac implantable electronic device infections (CIEDIs) present substantial challenges for infectious diseases specialists, encompassing diagnosis, management, and complex decision making involving patients, families, and multidisciplinary teams. This review, guided by a common clinical case presentation encountered in daily practice, navigates through the diagnostic process, management strategies in unique scenarios, long-term follow-up, and critical discussions required for CIEDIs.

A Novel Approach to Identifying Appropriate Candidates for Transvenous Lead Extraction

BACKGROUND

The need for transvenous lead extractions (TLEs) in the setting of cardiac implantable electronic device-(CIED) related infections continues to rise. Delays in referral for TLE in this setting are common and are associated with increased mortality.

OBJECTIVE

To describe the outcomes of a comprehensive approach, including an electronic medical record (EMR)-based notification algorithm designed to identify patients with active CIED-related infections to facilitate timely TLE.

METHODS

Following an interdepartmental education initiative at a high-volume extraction center, an EMR based notification algorithm generated alerts for all inpatients with a CIED who received intravenous antibiotics or had positive blood cultures between September 2022 and February 2024. Patients deemed to be high risk underwent an electrophysiology consultation and were managed at the discretion of the treating electrophysiologist. Demographics, procedural details, and clinical outcomes were analyzed.

RESULTS

1829 notifications were screened over the study period. Thirty-nine consults were generated (2%). Of these patients, 18 TLEs were performed (46%). Patients who underwent TLE had MSSA (56%), MRSA (22%), enterococcus (11%), Serratia (5.6%), or S. gallolyticus (5.6%) bacteremia. The median time from the review to consultation was 1 day (IQR: 0, 1 days) and review to TLE was 2 days (IQR: 1, 2.75 days). Survival in the extraction group was 67% after a median follow-up period of 133 days (IQR: 59, 223 days).

CONCLUSION

A comprehensive approach, including an EMR-based notification algorithm allowed for the early identification of patients who were appropriate candidates for TLE due to CIED-related infections. Use of this algorithm facilitated timely TLEs.

How to Approach Patients with Cardiac Implantable Electronic Devices and Bacteremia

The approach to a patient with a cardiac implantable electronic device (CIED) and bacteremia requires a high index of suspicion. The microorganism and duration of bacteremia affect the pretest probability of CIED infection. When transesophageal echocardiography findings are equivocal, fluorodeoxyglucose-PET/computed tomography can increase the sensitivity and specificity for CIED infection. Confirmed CIED infection warrants complete system extraction. In patients with persistent gram-positive bacteremia despite antimicrobial therapy and unclear involvement of the CIED, the device is sometimes empirically extracted. Long-term effects of extraction (such as risk of suboptimal/failed cardiac resynchronization therapy reimplant) should be factored into decisions regarding empiric CIED extraction.

Indications for Lead Extraction

Cardiac implantable electronic devices (CIEDs) are being implanted at increasing rates. Patients with CIEDs require more lead management in contemporary clinical practice, given the increased survival of heart failure patients. There are multiple indications for extraction with the strongest class I indications being in patients with CIED infections. Extraction with complete hardware removal is underutilized and often delayed when it is utilized in patients with CIED infections, resulting in higher mortality. Patient and provider preferences are critical to decision-making when considering extraction. Lead extraction referral and management care pathways are needed in order to optimize care for our patients with CIEDs.

Cardiovascular Implantable Electronic Device Infections: A Contemporary Review

Infections associated with cardiac implantable electronic devices (CIEDs) are increasing and are a cause of significant morbidity and mortality. This article summarizes the latest updates with respect to the epidemiology, microbiology, and risk factors for CIED-related infections. It also covers important considerations regarding the diagnosis, management, and prevention of these infections. Newer technologies such as leadless pacemakers and subcutaneous implantable cardioverters and defibrillators are discussed.

Pacemaker Pocket Erosion: A Critical Issue Requiring Immediate Attention

Cardiac implantable electronic devices (CIEDs), including pacemakers, implantable cardiac defibrillators (ICD), and cardiac resynchronization therapy (CRT) devices, regulate heart rate and rhythm in patients with cardiac conditions. With an aging population, CIED-related complications, especially pacemaker pocket infections, are rising. Risk factors include frailty, older age, and superficial device fixation, while risk mitigation involves larger pocket sizes, submuscular fixation, and absorbable antibacterial envelopes. The debate continues regarding the optimal timing for device removal and lead extraction. This report presents a case of a 77-year-old male with a history of atrial fibrillation and prior methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia, who was admitted with infection symptoms and a pacemaker erosion. Blood and wound cultures confirmed MSSA and the patient underwent successful lead and device extraction. He was treated with daptomycin and discharged two days after admission with close follow-up by infectious disease, cardiology, and wound care specialists. The case emphasizes the importance of timely intervention in CIED infections, highlighting occult bacteremia where no infection source is identified. Early removal, particularly within one day of presentation, led to a favorable outcome. Simple lead extraction was chosen because the device had been in place for less than a year, and age and comorbidities did not influence the decision. In the prior MSSA bacteremia episode, early lead and generator extraction might have prevented the second admission, reinforcing the value of early intervention. These findings underscore the need for vigilant monitoring and suggest that future guidelines could benefit from stratifying lead and device removal strategies based on implantation timing to enhance patient outcomes.

An Approach to Cardiac Implantable Electronic Device Pocket Infections: From Prevention to Diagnosis and Management

Cardiac implantable electronic device (CIED) infections are a highly morbid and potentially fatal complication of CIED implantation. Prompt diagnosis is paramount to the proper management of such infections. This review seeks to highlight the pathophysiology, risk factors, diagnostic approach, and prevention strategies for CIED infection, with an emphasis on pocket infection. Management will be discussed in detail, with complete device removal representing the standard of case, but with conservative management representing a potential alternative for patients at high risk for extraction. The high prevalence of CIED in the cardiac population renders understanding of this subject essential for the practicing clinician.

Outcomes of device extraction in patients with chronic kidney disease on renal replacement therapy and cardiac implantable electronic devicead infections

BACKGROUND

Patients with chronic kidney disease (CKD) on renal replacement therapy (RRT) are at high risk for cardiovascular implantable electronic device (CIED) infections. Although device extraction is standard management, it is often avoided in these patients because of high procedural risks.

OBJECTIVES

Evaluate the outcomes of CIED extraction in CKD on RRT patients with device infection.

METHODS

This study used data from the TriNetX research network. The International Classification of Diseases-10th Revision-Clinical Modification coding system was used to identify patients. Adults with a history of CKD on RRT and CIED infection were included. Patients with renal transplantation and prosthetic heart valves were excluded. Patients were stratified by device extraction. The primary outcome was mortality at 1 year.

RESULTS

A total of 530 patients were identified, of whom 30% (n = 159) underwent device extraction. After propensity score matching (PSM), 302 patients remained, with 151 in each group. Kaplan-Meier survival analysis demonstrated a significant 1-year survival benefit for patients in the device extraction group (59.2%) compared with the no-extraction group (48.8%, P = .043; hazard ratio [HR], 0.696; 95% confidence interval [CI], 0.489-0.991). Freedom from complications such as pericardial effusion was similar between groups. Sensitivity analysis using Cox proportional hazards, adjusted for baseline confounders, confirmed the survival benefit of extraction, with a reduced mortality risk (HR, 0.581; 95% CI, 0.382-0.883; P = .011).

CONCLUSION

In CKD on RRT patients with CIED infection, device extraction is associated with a reduction in all-cause mortality at 1 year. However, the rate of device extraction is low in this group.

Retrospective Review Identifying Patients With Bacteremia and Intracardiac Devices With an Electronic Health Record Advisory

BACKGROUND

Cardiovascular implantable electronic device (CIED) infections without early diagnosis, treatment, and proper follow-up are associated with increased morbidity, mortality, and worse outcomes.  Objective: This study aims to identify patients presenting for hospital admission with bacteremia and the presence of CIED by implementing a best practice advisory (BPA) notification in the electronic medical record to facilitate early consultation with the cardiac electrophysiology (EP) team and treatment.

METHODS

A BPA was implemented into the electronic medical record (EMR) EPIC in 2022 and was generated for any patient that presented to our health system with bacteremia and the presence of a CIED. The BPA gave the provider an option for EP consultation. Data was collected from EPIC from 2021 to 2023 using the International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD10-CM/PCS) codes to identify patients and comorbidities. A comparative analysis was conducted to determine the effectiveness of the BPA in increasing EP consults and cardiac device extraction procedures, as well as overall outcomes.

RESULTS

A total of 447 patients were diagnosed with bacteremia and the presence of a CIED during the study period, with 178 before the BPA and 269 status post-BPA. The BPA resulted in a nonsignificant increase in EP consultations from 19.66% to 25.88% (p = 0.168) and device extractions from 9.55% to 13.75% (p = 0.182). EP consults were a significant predictor for device extractions (odds ratio (OR) = 9.4644, p < 0.0001). The mortality rate decreased from 17.42% to 14.13% (p = 0.419), and the 30-day readmission decreased from 14.37% to 12.41% (p = 0.652).

CONCLUSION

While the BPA did not show significant improvements, its implementation shows promise over time with positive trends in consults, extractions, and in-hospital mortality.

Cardiac Device-related Infective Endocarditis and Retrosternal Abscess Treated with Percutaneous Lead Extraction and Antimicrobials: A Case Report

An 85-year-old man with a history of 2 open-heart surgeries (for aortic regurgitation and infective endocarditis [IE]) and pacemaker implantation for bradycardic atrial fibrillation presented with a fever. Transesophageal echocardiography revealed a pacemaker lead vegetation. Computed tomography showed a retrosternal abscess. He was diagnosed with acute heart failure and IE. Given the high surgical risk due to his age, acute heart failure, and surgical history, we decided against cardiac surgery. After lead extraction, a leadless pacemaker was inserted, and antimicrobial therapy was administered. The patient was discharged on day 48, highlighting a strategy for managing complex cardiac device-related IE.

Impact of infective versus sterile transvenous lead removal on 30-day outcomes in cardiac implantable electronic devices

BACKGROUND

Transvenous lead removal (TLR) is associated with increased mortality and morbidity. This study sought to evaluate the impact of TLR on in-hospital mortality and outcomes in patients with and without CIED infection.

METHODS

From January 1, 2017, to December 31, 2020, we utilized the nationally representative, all-payer, Nationwide Readmissions Database to assess patients who underwent TLR. We categorized TLR as indicated for infection, if the patient had a diagnosis of bacteremia, sepsis, or endocarditis during the initial admission. Conversely, if none of these conditions were present, TLR was considered sterile. The impact of infective vs sterile indications of TLR on mortality and major adverse events was studied.

RESULTS

Out of the total 25,144 patients who underwent TLR, 14,030 (55.8%) received TLR based on sterile indications, while 11,114 (44.2%) received TLR due to device infection, with 40.5% having systemic infection and 59.5% having isolated pocket infection. TLR due to infective indications was associated with a significant in-hospital mortality (5.59% vs 1.13%; OR = 5.16; 95% CI 4.33-6.16; p < 0.001). Moreover, when compared with sterile indications, TLR performed due to device infection was associated with a considerable risk of thromboembolic events including pulmonary embolism and stroke (OR = 3.80; 95% CI 3.23-4.47, p < 0.001). However, there was no significant difference in the conversion to open heart surgery (1.72% vs. 1.47%, p < 0.111), and infection was not an independent predictor of cardiac (OR = 1.12; 95% CI 0.97-1.29) or vascular complications (OR = 1.12; 95% CI 0.73-1.72) between the two groups.

CONCLUSION

Higher in-hospital mortality and rates of thromboembolic events associated with TLR resulting from infective indications may warrant further pursuing this diagnosis in patients.

[Complications of permanent cardiac pacing: a retrospective observational study of 462 cases from the University Hospital Center Hedi Chaker of Sfax, Tunisia]

The benefits of permanent cardiac pacing have been widely demonstrated. However, the literature on complications remains inconsistent. We lack precise information about the frequency of complications and their predictive factors in our center. The purpose of this study was to determine the frequency of complications related to permanent cardiac pacing in our centre and to specify their predictive factors. We conducted a retrospective, observational, descriptive and analytical study. It involved patients who underwent an implantable electronic device (CIED) procedure, such as a pacemaker (PM) or implantable cardioverter-defibrillator (ICD) at the University Hospital Center of Sfax, Tunisia between January 2009 and December 2013. All clinical and paraclinical characteristics of the patients, their procedural data and any potential complications related to CIED implantation were collected (infectious complications, pocket hematomas, lead-related complications, vascular access complications, and complication-related mortality). Appropriate statistical tests were used to analyze the incidence of complications and their associated factors through multivariate analysis and to perform a survival analysis. We collected data from 462 procedures, including 420 PMs and 42 ICDs. The population had an average age of 72 ± 15 years. Hypertension was present in 55.1% of cases, diabetes in 22.3%, and 63.38% had underlying heart disease. A total of 64 complications were noted, accounting for 11.5% of the procedures. Complications were significantly more frequent with ICDs than PMs (23.8% vs. 10.2%; p=0.04). The incidence of infectious complications was 1.96%. Associated risk factors included diabetes (adjusted OR: 4.35, 95% CI 1.08-17.48; p=0.038) and reduced left ventricular ejection fraction (adjusted OR: 9.2, 95% CI 1.83-46.12; p=0.007). The incidence of pocket hematomas was 1.53%, with its associated risk factor being an indication for therapeutic anticoagulation (adjusted OR: 29.05, 95% CI 3.42-246.57; p=0.002). Lead-related complications were the most common (73.4% of complications). Their independent predictive factor was the number of manipulations greater than one (adjusted OR: 3.66, 95% CI 0.98-13.61; p=0.05). Among this subgroup, lead displacement was the most frequent (40.05%), with the presence of hypertensive heart disease as an associated risk factor (adjusted OR: 3.99, 95% CI 1.2-13.1; p=0.019). Vascular access complications were rare, occurring in 0.21% of cases. Mortality related to complications of cardiac device implantation was high (13.2%), particularly in the case of infectious complications (p=0.04). Overall survival at 5 years was 84.5%. The incidence of IEDC-related complications in the short and long term at our center was high, with a significant associated mortality, although comparable to the literature data. By identifying associated risk factors such as diabetes, heart failure, therapeutic anticoagulation, and repeat surgeries, we can adopt an informed therapeutic approach to reduce complications.

Outcomes of complete removal versus conservative therapy in cardiac implantable electronic device infections - A systematic review and Meta-analysis

BACKGROUND

Complete removal of cardiac implantable electronic devices (CIEDs) is recommended in patients with CIED infections, including both systemic and localized pocket infection. The aim of the study was to provide an up-to-date and comprehensive assessment of evidence relating to the effect of complete CIED extraction in patients with a CIED infection.

METHODS

We performed a systematic review and meta-analysis of studies reporting short- and mid-term outcomes in patients who had a device infection or infective endocarditis (IE) and underwent complete removal of the cardiac device (generator and leads) compared to those who received conservative therapy (no removal, partial removal, local antibiotic infiltration or isolated antibiotic therapy). The primary outcome was reinfection/relapse. Secondary outcomes were short-term (30-day/in-hospital) and mid-term (mean follow-up: 43.0 months) mortality. Random effects model was performed.

RESULTS

Thirty-two studies met the criteria for inclusion in the final analysis. Patients with complete CIED extraction (n = 905) exhibited a lower rate of relapse/re-infection compared to patients (n = 195) with a conservative treatment approach (n = 195, OR 0.02, 95%CI 0.01-0.06, p < 0.0001, mean-follow-up: 16.1 months). Additionally, these patients displayed a lower short- (OR 0.40, 95%CI 0.23-0.69, p = 0.01) and mid-term (OR 0.52, 95%CI 0.34-0.78, p = 0.002) mortality.

CONCLUSIONS

The analysis indicates that patients with a CIED infection who undergo complete CIED extraction exhibit a lower rate of relapse/re-infection. Additionally, a lower short- and mid-term mortality is observed, although it is acknowledged that this outcome may be influenced by treatment allocation bias.

Heart failure - An unexplored risk factor for infective endocarditis after pacemaker implantation

BACKGROUND

With the widespread use of permanent pacemakers (PPM), and increased mortality associated with pacemaker endocarditis, it is essential to evaluate comorbidities that could potentially increase the risk of infective endocarditis (IE). Heart failure (HF), a common comorbidity, has not been well studied as an independent risk factor for development of IE in individuals with PPM.

METHODS

The US National Inpatient Sample database was used to sample individuals with PPM. Patients with concomitant implantable cardioverter defibrillator, acute heart failure, history of endocarditis, intravenous drug use, prosthetic heart valves, or central venous catheter infection were excluded. Propensity matching was performed to match patients with and without HF. Pre- and post-match logistic regression was performed to assess HF as an independent risk factor for IE. A subgroup analysis was performed comparing IE rates between patients with HF with reduced (HFrEF) vs preserved (HFpEF) ejection fraction.

RESULTS

Out of 333,571 patients with PPM included in the study, 121,862 (37 %) had HF. HF patients were older and had a higher prevalence of females. All comorbidities except for dental disease and cancer were more prevalent in the HF group. Patients with HF were 1.30 times more likely to develop IE [OR: 1.30 (1.16-1.47); p < 0.001]. The two cohorts were then matched for age, gender, and 20 comorbidities using a 1:1 propensity score matching algorithm. After matching, HF was still independently associated with increased risk of IE [OR: 1.62 (1.36-1.93); p < 0.001]. In our sub-group analysis, HFrEF and HFpEF patients had similar IE rates.

CONCLUSION

In PPM population, HF was associated with an increased risk of IE compared to those without HF. We hypothesize that HF being a low-flow and high-inflammatory state might have contributed to this increased risk. Larger studies are required to corroborate our findings and evaluate the need for antimicrobial prophylaxis for this population.

Infective endocarditis

First described more than 350 years ago, infective endocarditis represents a global health concern characterised by infections affecting the native or prosthetic heart valves, the mural endocardium, a septal defect, or an indwelling cardiac device. Over recent decades, shifts in causation and epidemiology have been observed. Echocardiography remains pivotal in the diagnosis of infective endocarditis, with alternative imaging modalities gaining significance. Multidisciplinary management requiring expertise of cardiologists, cardiovascular surgeons, infectious disease specialists, microbiologists, radiologists and neurologists, is imperative. Current recommendations for clinical management often rely on observational studies, given the limited number of well conducted randomised controlled trials studying infective endocarditis due to the rarity of the disease. In this Seminar, we provide a comprehensive overview of optimal clinical practices in infective endocarditis, highlighting key aspects of pathophysiology, pathogens, diagnosis, management, prevention, and multidisciplinary approaches, providing updates on recent research findings and addressing remaining controversies in diagnostic accuracy, prevention strategies, and optimal treatment.

Utility of an Externalized Temporary Transvenous Implantable Cardioverter-defibrillator System in the Setting of Ventricular Tachycardia Storm and Concurrent Device Infection Requiring Extraction

With the expanding use of cardiac implantable electronic device (CIED) therapy, intravascular device infections are becoming more common. In the case of transvenous implantable cardioverter-defibrillator (ICD) infections requiring extraction for bacterial clearance, there remains no standard method to deliver temporary ICD therapy following device removal. We present a case of persistent bacteremia complicated by monomorphic ventricular tachycardia (VT) electrical storm where biventricular ICD system extraction was performed and a temporary transvenous dual-coil lead with an externalized ICD generator was used to treat VT episodes prior to the re-implantation of a new permanent system. This case demonstrates the utility of a temporary externalized transvenous ICD system in the successful detection and pace-termination of VT, thereby reducing episodes of painful and potentially harmful external defibrillator shocks during the treatment of CIED infection.

Outcome and microbiological findings of patients with cardiac implantable electronic device infection

INTRODUCTION

Infections associated with cardiac implantable electronic devices (CIEDs) are a multifactorial disease that leads to increased morbidity and mortality.

OBJECTIVE

The aim was to analyze patient-, disease- and treatment-related characteristics including microbiological and bacterial spectrum according to survival status and to identify risk factors for 1- and 3-year mortality in patients with local and systemic CIED infection.

METHODS

In a retrospective cohort study, we analyzed data from patients with CIED-related local or systemic infection undergoing successful transvenous lead extraction (TLE). Survival status as well as incidence and cause of rehospitalization were recorded. Microbiology and antibiotics used as first-line therapy were compared according to mortality. Independent risk factors for 1- and 3-year mortality were determined.

RESULTS

Data from 243 Patients were analyzed. In-hospital mortality was 2.5%. Mortality rates at 30 days, 1- and 3 years were 4.1%, 18.1% and 30%, respectively. Seventy-four (30.5%) patients had systemic bacterial infection. Independent risk factors for 1-year mortality included age (OR 1.05 [1.01-1.10], p = 0.014), NT-proBNP at admission (OR 4.18 [1.81-9.65], p = 0.001), new onset or worsened tricuspid regurgitation after TLE (OR 6.04 [1.58-23.02], p = 0.009), and systemic infection (OR 2.76 [1.08-7.03], p = 0.034), whereas systemic infection was no longer an independent risk factor for 3-year mortality. Staphylococcus aureus was found in 18.1% of patients who survived and in 25% of those who died, p = 0.092. There was a high proportion of methicillin-resistant strains among coagulase-negative staphylococci (16.5%) compared to Staphylococcus aureus (1.2%).

CONCLUSIONS

Staphylococci are the most common causative germs of CIED-infection with coagulase-negative staphylococci showing higher resistance rates to antibiotics. The independent risk factors for increased long-term mortality could contribute to individual risk stratification and well-founded treatment decisions in clinical routine. Especially the role of tricuspid regurgitation as a complication after TLE should be investigated in future studies.

Infectious mass debulking in lead-associated endocarditis with a percutaneous aspiration system

AIMS

Debulking of infective mass to reduce the burden if infective material is a fundamental principle in the surgical management of infection. The aim of this study was to investigate the validity of this principle in patients undergoing transvenous lead extraction in the context of bloodstream infection (BSI).

METHODS AND RESULTS

We performed an observational single-centre study on patients that underwent transvenous lead extraction due to a BSI, with or without lead-associated vegetations, in combination with a percutaneous aspiration system during the study period 2015-22. One hundred thirty-seven patients were included in the final analysis. In patients with an active BSI at the time of intervention, the use of a percutaneous aspiration system had a significant impact on survival (log-rank: P = 0.0082), while for patients with a suppressed BSI at the time of intervention, the use of a percutaneous aspiration system had no significant impact on survival (log-rank: P = 0.25).

CONCLUSION

A reduction of the infective burden by percutaneous debulking of lead vegetations might improve survival in patients with an active BSI.

Open Chest Approach Lead Extraction in a Patient with a Large Vegetation: The Importance of Multidisciplinary Approach, Advanced Imaging, and Procedural Planning

We present a complex case of cardiac implantable electronic device infection and extraction in the setting of bacteremia, large lead vegetation, and patent foramen ovale. Following a comprehensive preprocedural workup including transesophageal echocardiogram and computed tomography lead extraction protocol, in addition to the involvement of multiple subspecialties, an open chest approach to extraction was deemed a safer option for eradication of the patient's infection. Despite percutaneous techniques having evolved as the preferred extraction method during the last few decades, this case demonstrates the importance of a thorough evaluation at an experienced center to determine the need for open chest extraction.

Perioperative management of patients with cardiac implantable electronic devices

The use of cardiac implantable electronic devices (CIEDs) has increased significantly in recent years. Consequently, more patients with CIEDs will undergo surgery during their lifetime, and thus the involvement of anesthesiologists in the perioperative management of CIEDs is increasing. With ongoing advancements in technology, many types of CIEDs have been developed, including permanent pacemakers, leadless pacemakers, implantable cardioverter defibrillators, cardiac resynchronization therapy-pacemakers/defibrillators, and implantable loop recorders. The functioning of CIEDs exposed to an electromagnetic field can be affected by electromagnetic interference, potential sources of which can be found in the operating room. Thus, to prevent potential adverse events caused by electromagnetic interference in the operating room, anesthesiologists must have knowledge of CIEDs and be able to identify each type. This review focuses on the perioperative management of patients with CIEDs, including indications for CIED implantation to determine the baseline cardiovascular status of patients; concerns associated with CIEDs before and during surgery; perioperative management of CIEDs, including magnet application and device reprogramming; and additional perioperative provisions for patients with CIEDs. As issues such as variations in programming capabilities and responses to magnet application according to device can be challenging, this review provides essential information for the safe perioperative management of patients with CIEDs.

Strategies to maximize lead tensile strength during extraction in three families of pacing leads

BACKGROUND

Traction force that can be applied to an extraction rail is based on lead tensile strength, a product of its construction. A strong rail allows safe advancement of the extraction sheath. This study expands previous work providing strategies to optimize INGEVITY rail strength.

OBJECTIVE

The purpose of this study was to measure forces that leads encounter in a simulated extraction procedure, determine lead response, and develop extraction recommendations for INGEVITY, INGEVITY+, and FINELINE II lead families.

METHODS

Leads were positioned in a simulated right atrial appendage implant. Subsequent traction forces enabled evaluation of lead tensile strength and effectiveness of preparation/extraction techniques.

RESULTS

Significant findings include (1) preserving the lead terminal pin did not decrease lead tensile strength and typically maximized it; (2) the weakest region is between the cathode and anode; (3) mid lead scar increases traction force tolerance until that scar is removed; and (4) optimal rail strength was observed using a multivenous approach with a femoral snare. Unique lead family findings include increased tensile strength of FINELINE II polyurethane vs silicone and INGEVITY active fixation vs passive fixation.

CONCLUSION

This study teaches the implanting clinician there are specific extraction techniques available to improve the removal of leads that may be the best option for a patient's clinical needs. Bench testing demonstrates that lead construction drives lead behavior during an extraction. Preserving the lead terminal pin provides consistent and, in most cases, optimal rail strength. If clinically indicated, a multivenous approach using a femoral snare significantly increases rail strength and protects the vulnerable lead tip.

Prevention and Risk Assessment of Cardiac Device Infections in Clinical Practice

The implantation of cardiac electronic devices (CIEDs), including pacemakers and defibrillators, has become increasingly prevalent in recent years and has been accompanied by a significant rise in cardiac device infections (CDIs), which pose a substantial clinical and economic burden. CDIs are associated with hospitalizations and prolonged antibiotic therapy and often necessitate device removal, leading to increased morbidity, mortality, and healthcare costs worldwide. Approximately 1-2% of CIED implants are associated with infections, making this a critical issue to address. In this contemporary review, we discuss the burden of CDIs with their risk factors, healthcare costs, prevention strategies, and clinical management.

Inflammatory biomarkers as predictors of systemic vs isolated pocket infection in patients undergoing transvenous lead extraction

Background

Cardiovascular implantable electronic device (CIED) infections are a common indication for device extraction. Early diagnosis and complete system removal are crucial to reduce morbidity and mortality. The lack of clear infectious symptoms makes the diagnosis of pocket infections challenging and may delay referral for extraction.

Objective

We aimed to determine if inflammatory biomarkers can help diagnose CIED isolated pocket infection.

Methods

We performed a retrospective analysis of all patients undergoing transvenous lead extraction for CIED infection at the University of California San Diego from 2012 to 2022 (N = 156). Patients were classified as systemic infection (n = 88) or isolated pocket infection (n = 68). Prospectively collected preoperative procalcitonin (PCT), C-reactive protein, and white blood cell count were compared between groups.

Results

Pairwise comparisons revealed that the systemic infection group had a higher PCT than the control group (P < .001) and the pocket infection group (P = .009). However, there was no significant difference in PCT value between control subjects and isolated pocket infection subjects. Higher white blood cell count was only associated with systemic infection when compared with our control group (P = .018).

Conclusion

In patients diagnosed with CIED infections requiring extraction, inflammatory biomarkers were not elevated in isolated pocket infection. Inflammatory markers are not predictive of the diagnosis of pocket infections, which ultimately requires a high level of clinical suspicion.

Update on Cardiovascular Implantable Electronic Device Infections and Their Prevention, Diagnosis, and Management: A Scientific Statement From the American Heart Association: Endorsed by the International Society for Cardiovascular Infectious Diseases

The American Heart Association sponsored the first iteration of a scientific statement that addressed all aspects of cardiovascular implantable electronic device infection in 2010. Major advances in the prevention, diagnosis, and management of these infections have occurred since then, necessitating a scientific statement update. An 11-member writing group was identified and included recognized experts in cardiology and infectious diseases, with a career focus on cardiovascular infections. The group initially met in October 2022 to develop a scientific statement that was drafted with front-line clinicians in mind and focused on providing updated clinical information to enhance outcomes of patients with cardiovascular implantable electronic device infection. The current scientific statement highlights recent advances in prevention, diagnosis, and management, and how they may be incorporated in the complex care of patients with cardiovascular implantable electronic device infection.

Lead Extraction and Mortality Among Patients With Cardiac Implanted Electronic Device Infection

Importance

Complete hardware removal is a class I recommendation for cardiovascular implantable electronic device (CIED) infection, but practice patterns and outcomes remain unknown.

Objective

To quantify the number of Medicare patients with CIED infections who underwent implantation from 2006 to 2019 and lead extraction from 2007 to 2019 to analyze the outcomes in these patients in a nationwide clinical practice cohort.

Design, Setting, and Participants

This cohort study included fee-for-service Medicare Part D beneficiaries from January 1, 2006, to December 31, 2019, who had a de novo CIED implantation and a CIED infection more than 1 year after implantation. Data were analyzed from January 1, 2005, to December 31, 2019.

Exposure

A CIED infection, defined as (1) endocarditis or infection of a device implant and (2) documented antibiotic therapy.

Main Outcomes and Measures

The primary outcomes of interest were device infection, device extraction, and all-cause mortality. Time-varying multivariable Cox proportional hazards regression models were used to evaluate the association between extraction and survival.

Results

Among 1 065 549 patients (median age, 78.0 years [IQR, 72.0-84.0 years]; 50.9% male), mean (SD) follow-up was 4.6 (2.9) years after implantation. There were 11 304 patients (1.1%) with CIED infection (median age, 75.0 years [IQR, 67.0-82.0 years]); 60.1% were male, and 7724 (68.3%) had diabetes. A total of 2102 patients with CIED infection (18.6%) underwent extraction within 30 days of diagnosis. Infection occurred a mean (SD) of 3.7 (2.4) years after implantation, and 1-year survival was 68.3%. There was evidence of highly selective treatment, as most patients did not have extraction within 30 days of diagnosed infection (9202 [81.4%]), while 1511 (13.4%) had extraction within 6 days of diagnosis and 591 (5.2%) had extraction between days 7 and 30. Any extraction was associated with lower mortality compared with no extraction (adjusted hazard ratio [AHR], 0.82; 95% CI, 0.74-0.90; P < .001). Extraction within 6 days was associated with even lower risk of mortality (AHR, 0.69; 95% CI, 0.61-0.78; P < .001).

Conclusions and Relevance

In this study, a minority of patients with CIED infection underwent extraction. Extraction was associated with a lower risk of death compared with no extraction. The findings suggest a need to improve adherence to guideline-directed care among patients with CIED infection.

Clinical and financial outcomes of hospitalizations for cardiac device infection during the COVID-19 pandemic in the US

BACKGROUND

Cardiac device infection (CDI) can occur in up to 2.2% of patients after device placement, with mortality rates exceeding 15%. Although device removal is standard management, the COVID-19 pandemic has been associated with resource diversion and decreased patient presentation for cardiovascular disease. We ascertained the association of the COVID-19 pandemic with outcomes and resource utilization after admission for CDI.

METHODS

The 2016-2020 National Inpatient Sample was used to retrospectively study all adult admissions for CDI. Patients admitted between March and December, 2020 were classified as the pandemic cohort, with the rest pre-pandemic. The primary outcome was major adverse events (MAE), with secondary outcomes of overall length of stay (LOS), post-device removal LOS, time to device replacement, and hospitalization costs. MAE was a combination of in-hospital mortality and select complications. Multivariable regression models were developed to determine the relationship between the pandemic and the aforementioned outcomes.

RESULTS

Of an estimated 190,160 patients, 14.3% comprised the pandemic cohort; 2.4% of these patients were COVID-19 positive. The pandemic cohort was older, less commonly female, and had higher rates of congestive heart failure. After adjustment, the pandemic was not associated with altered odds of MAE, device removal, or subsequent device replacement. The pandemic was, however, associated with decreased adjusted overall LOS (β -0.38 days) and days to device replacement (β -0.83 days). The pandemic was likewise associated with $2,000 increased adjusted hospitalization costs.

CONCLUSION

The pandemic did not have a significant impact on clinical outcomes in patients admitted for CDI, despite higher hospitalization costs and decreased length of stay.

Transvenous lead extraction versus surgical lead extraction or conservative treatment for cardiac implantable electronic device infections: Propensity score-weighted analyses of a nationwide claim-based database

INTRODUCTION

Infection is one of the most important complications associated with cardiac implantable electronic device (CIED) therapy. The number of reports comparing the outcomes of transvenous lead extraction (TLE), surgical lead extraction, and conservative treatment for CIED infections using a real-world database is limited. This study investigated the association between the treatment strategies for CIED infections and their outcomes.

METHODS

We performed a retrospective analysis of 3605 patients with CIED infections admitted to 681 hospitals using a nationwide claim-based database collected between April 2012 and March 2018.

RESULTS

We divided the 3605 patients into TLE (n = 938 [26%]), surgical lead extraction (n = 182 [5.0%]), and conservative treatment (n = 2485 [69%]) groups. TLE was performed more frequently in younger patients and at larger hospitals (p for trend < .001 for both). The rate of TLE increased during the study period, whereas that of surgical lead extraction decreased (p for trend < .001 for both). TLE was associated with lower in-hospital mortality (vs. surgical lead extraction: odds ratio [OR], 0.20; 95% CI, 0.06-0.70; vs. conservative treatment: OR, 0.45; 95% CI: 0.22-0.94) and lower 30-day readmission rates (vs. surgical lead extraction: OR, 0.18; 95% CI: 0.06-0.56; vs. conservative treatment: OR, 0.06; 95% CI, 0.03-0.13) in propensity score-weighted analyses.

CONCLUSIONS

Only 26% of patients hospitalized for CIED infections received TLE. TLE was associated with significantly lower in-hospital mortality and 30-day recurrence rates than surgical lead extraction and conservative treatment, suggesting that TLE should be more widely recommended as a first-line treatment for CIED infections.

Clinical Approach to Evaluation of Underlying Cardiac Device Infection in Patients Hospitalized with Bacteremia

More than 400,000 cardiac implantable electronic devices (CIEDs), including permanent pacemakers, implantable cardioverter-defibrillators, and cardiac resynchronization therapy devices, are implanted every year in the United States (US). Infection is a serious complication of CIED therapy and is associated with high morbidity and mortality. While CIED pocket infection can be diagnosed based on clinical exam findings, positive blood culture may be the only manifestation of CIED lead infection. Thus, management of bacteremia in patients living with CIEDs requires special consideration. This review summarizes contemporary data in the context of the recently updated 2023 Duke-International Society for Cardiovascular Infectious Diseases Criteria for Infective Endocarditis. We have synthesized these data into an algorithmic approach to streamline the diagnostic evaluation of CIED infection in patients presenting with bacteremia.

Transvenous lead extraction of implantable cardioverter-defibrillators: A comprehensive outcome-and risk factor analysis

BACKGROUND

Device complications, such as infection or lead dysfunction necessitating transvenous lead extraction (TLE) are continuously rising amongst patients with transvenous implantable-cardioverter-defibrillator (ICD).

OBJECTIVES

Aim of this study was to characterize the procedural outcome and risk-factors of patients with indwelling 1- and 2-chamber ICD undergoing TLE.

METHODS

We conducted a subgroup analysis of all ICD patients in the GALLERY (GermAn Laser Lead Extraction RegistrY) database. Predictors for procedural failure and all-cause mortality were assessed.

RESULTS

We identified 842 patients with an ICD undergoing TLE with the mean age of 62.8 ± 13.8 years. A total number of 1610 leads were treated with lead dysfunction (48.5%) as leading indication for extraction, followed by device-related infection (45.4%). Lead-per-patient ratio was 1.91 ± 0.88 and 60.0% of patients had dual-coil defibrillator leads. Additional extraction tools, such as mechanical rotating dilator sheaths and snares were utilized in 6.5% of cases. Overall procedural complications occurred in 4.3% with 2.0% major complications and a procedure-related mortality of 0.8%. Clinical success rate was 97.9%. All-cause in-hospital mortality was 3.4%, with sepsis being the leading cause for mortality. Multivariate analysis revealed lead-age ≥10 years (OR:5.82, 95%CI:2.1-16.6; p = .001) as independent predictor for procedural failure. Systemic infection (OR:9.57, 95%CI:2.2-42.4; p < .001) and procedural complications (OR:8.0, 95%CI:2.8-23.3; p < .001) were identified as risk factors for all-cause mortality.

CONCLUSIONS

TLE is safe and efficacious in patients with 1- and 2-chamber ICD. Although lead dysfunction is the leading indication for extraction, systemic device-related infection is the main driver of all-cause mortality for ICD patients undergoing TLE.

Transvenous Lead Extraction: Work in Progress

Cardiac implantable electronic devices are the cornerstone of cardiac rhythm management, with a significant number of implantations annually. A rising prevalence of cardiac implantable electronic devices coupled with widening indications for device removal has fuelled a demand for transvenous lead extraction (TLE). With advancement of tools and techniques, the safety and efficacy profile of TLE has significantly improved since its inception. Despite these advances, TLE continues to carry risk of significant complications, including a superior vena cava injury and mortality. However, innovative approaches to lead extraction, including the use of the jugular and femoral accesses, offers potential for further gains in safety and efficacy. In this review, the indications and risks of TLE are discussed while examining the evolution of this procedure from simple traction to advanced methodologies, which have contributed to a significant improvement in safety and efficacy.

Procedure, management, and outcome of subcutaneous implantable cardioverter-defibrillator extraction in clinical practice

AIMS

Subcutaneous implantable cardioverter-defibrillator (S-ICD) therapy is expanding rapidly. However, there are few data on the S-ICD extraction procedure and subsequent patient management. The aim of this analysis was to describe the procedure, management, and outcome of S-ICD extractions in clinical practice.

METHODS AND RESULTS

We enrolled consecutive patients who required complete S-ICD extraction at 66 Italian centres. From 2013 to 2022, 2718 patients undergoing de novo implantation of an S-ICD were enrolled. Of these, 71 required complete S-ICD system extraction (17 owing to infection). The S-ICD system was successfully extracted in all patients, and no complications were reported; the median procedure duration was 40 (25th-75th percentile: 20-55) min. Simple manual traction was sufficient to remove the lead in 59 (84%) patients, in whom lead-dwelling time was shorter [20 (9-32) months vs. 30 (22-41) months; P = 0.032]. Hospitalization time was short in the case of both non-infectious [2 (1-2) days] and infectious indications [3 (1-6) days]. In the case of infection, no patients required post-extraction intravenous antibiotics, the median duration of any antibiotic therapy was 10 (10-14) days, and the re-implantation was performed during the same procedure in 29% of cases. No complications arose over a median of 21 months.

CONCLUSION

The S-ICD extraction was safe and easy to perform, with no complications. Simple traction of the lead was successful in most patients, but specific tools could be needed for systems implanted for a longer time. The peri- and post-procedural management of S-ICD extraction was free from complications and not burdensome for patients and healthcare system.

CLINICAL TRIAL REGISTRATION

URL: http://clinicaltrials.gov/Identifier: NCT02275637.

Low Utilization of Lead Extraction Among Patients With Infective Endocarditis and Implanted Cardiac Electronic Devices

BACKGROUND

Cardiac implantable electronic device (CIED)-associated infections are associated with substantial morbidity, mortality, and costs. Guidelines have cited endocarditis as a Class I indication for transvenous lead removal/extraction (TLE) among patients with CIEDs.

OBJECTIVES

The authors sought to study utilization of TLE among hospital admissions with infective endocarditis using a nationally representative database.

METHODS

Using the Nationwide Readmissions Database (NRD), 25,303 admissions for patients with CIEDs and endocarditis between 2016 and 2019 were evaluated on the basis of International Classification of Diseases-10th Revision, Clinical-Modification (ICD-10-CM) codes.

RESULTS

Among admissions for patients with CIEDs and endocarditis, 11.5% were managed with TLE. The proportion undergoing TLE increased significantly from 2016 to 2019 (7.6% vs 14.9%; P 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, 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 (adjusted OR: 0.47; 95% CI: 0.37-0.60 by multivariable logistic regression, and adjusted 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.

Early Lead Extraction for Infected Implanted Cardiac Electronic Devices: JACC Review Topic of the Week

Infection remains a serious complication associated with the cardiac implantable electronic devices (CIEDs), leading to substantial clinical and economic burden globally. This review assesses the burden of cardiac implantable electronic device infection (CIED-I), evidence for treatment recommendations, barriers to early diagnosis and appropriate therapy, and potential solutions. Multiple clinical practice guidelines recommended complete system and lead removal for CIED-I when appropriate. CIED extraction for infection has been consistently reported with high success, low complication, and very low mortality rates. Complete and early extraction was associated with significantly better clinical and economic outcome compared with no or late extraction. However, significant gaps in knowledge and poor recommendation compliance have been reported. Barriers to optimal management may include diagnostic delay, knowledge gaps, and limited access to expertise. A multipronged approach, including education of all stakeholders, a CIED-I alert system, and improving access to experts, could help bring paradigm shift in the treatment of this serious condition.

Clinical and Epidemiological Characteristics of Persistent Bacteremia: A Decadal Observational Study

Background: Bloodstream infections (BSIs), including persistent bacteremia (PB), are a leading source of morbidity and mortality globally. PB has a higher mortality rate than non- PB, but the clinical aspects of PB in terms of the causative pathogens and the presence of clearance of PB are not well elucidated. Therefore, this study aimed to describe the clinical and epidemiological characteristics of PB in a real-world clinical setting. Methods: We performed a retrospective observational survey of patients who underwent blood culture between January 2012 and December 2021 at Tohoku University Hospital. Cases of PB were divided into three groups depending on the causative pathogen: gram-positive cocci (GPC), gram-negative rods (GNRs), and Candida spp. For each group, we examined the clinical and epidemiological characteristics of PB, including differences in clinical features depending on the clearance of PB. The main outcome variable was mortality, assessed as early (30-day), late (30-90 day), and 90-day mortality. Results: Overall, we identified 31,591 cases of single bacteremia; in 6709 (21.2%) cases, the first blood culture was positive, and in 3124 (46.6%) cases, a follow-up blood culture (FUBC) was performed. Of the cases with FUBCs, 414 (13.2%) were confirmed to be PB. The proportion of PB cases caused by Candida spp. was significantly higher (29.6%, 67/226 episodes) than that for GPC (11.1%, 220/1974 episodes, p < 0.001) and GNRs (12.1%, 100/824 episodes, p < 0.001). The Candida spp. group also had the highest late (30-90 day) and 90-day mortality rates. In all three pathogen groups, the subgroup without the clearance of PB tended to have a higher mortality rate than the subgroup with clearance. Conclusions: Patients with PB due to Candida spp. have a higher late (30-90 day) and 90-day mortality rate than patients with PB due to GPC or GNRs. In patients with PB, FUBCs and confirming the clearance of PB are useful to improve the survival rate.

Atrial Fibrillation and Transvenous Lead Extraction-A Comprehensive Subgroup Analysis of the GermAn Laser Lead Extraction RegistrY (GALLERY)

Background: Atrial fibrillation is the most common arrhythmia and has been described as driver of cardiovascular morbidity and risk factor for cardiac device-related complications, as well as in transvenous lead extraction (TLE). Objectives: Aim of this study was to characterize the procedural outcome and risk-factors of patients with atrial fibrillation (AF) undergoing TLE. Methods: We performed a subgroup analysis of all AF patients in the GALLERY (GermAn Laser Lead Extraction RegistrY) database. Predictors for all-cause mortality were assessed. Results: A total number of 510 patients with AF were identified with a mean age of 74.0 ± 10.3 years. Systemic infection (38.4%) was the leading cause for TLE, followed by local infection (37.5%) and lead dysfunction (20.4%). Most of the patients (45.9%) presented with pacemaker systems to be extracted. The total number of leads was 1181 with a 2.3 ± 0.96 leads/patient. Clinical procedural success was achieved in 97.1%. Occurrence of major complications was 1.8% with a procedure-related mortality of 1.0%. All-cause mortality was high with 5.9% and septic shock being the most common cause. Systemic device infection (OR: 49.73; 95% CI: 6.56−377.09, p < 0.001), chronic kidney disease (CKD; OR: 2.67; 95% CI: 1.01−7.03, p = 0.048) and a body mass index < 21 kg/m2 (OR: 6.6; 95% CI: 1.68−25.87, p = 0.007) were identified as independent predictors for all-cause mortality. Conclusions: TLE in AF patients is effective and safe, but in patients with systemic infection the mortality due to septic shock is high. Systemic infection, CKD and body mass index <21 kg/m2 are risk factors for death in patient with AF undergoing TLE.

Cardiac Implantable Electronic Devices Infection Assessment, Diagnosis and Management: A Review of the Literature

The use of increasingly complex cardiac implantable electronic devices (CIEDs) has increased exponentially in recent years. One of the most serious complications in terms of mortality, morbidity and financial burden is represented by infections involving these devices. They may affect only the generator pocket or be generalised with lead-related endocarditis. Modifiable and non-modifiable risk factors have been identified and they can be associated with patient or procedure characteristics or with the type of CIED. Pocket and systemic infections require a precise evaluation and a specialised treatment which in most cases involves the removal of all the components of the device and a personalised antimicrobial therapy. CIED retention is usually limited to cases where infection is unlikely or is limited to the skin incision site. Optimal re-implantation timing depends on the type of infection and on the results of microbiological tests. Preventive strategies, in the end, include antibiotic prophylaxis before CIED implantation, the possibility to use antibacterial envelopes and the prevention of hematomas. The aim of this review is to investigate the pathogenesis, stratification, diagnostic tools and management of CIED infections.

Prevention and Management of Cardiac Implantable Electronic Device Infections: State-of-the-Art and Future Directions

Cardiac implantable electronic device (CIED) infection is an increasingly common complication of device therapy. CIED infection confers significant patient morbidity and health care expenditure, hence it is essential that clinicians recognise the contemporary strategies for predicting, reducing and treating these events. Recent technological advances-in particular, the development of antimicrobial envelopes, leadless devices and validated risk scores-present decision-makers with novel strategies for managing this expanding patient population. This review summarises the key issues facing CIED patients and their physicians, and explores the supporting evidence for the latest therapeutic developments in this field.

"Shift and cover technique": conservative management of complications for the rescue of S-ICD subcutaneous implantable defibrillator systems

BACKGROUND

The risk of complications has been shown to be lower with subcutaneous implantable defibrillator (S-ICD) than with conventional ICDs. Given the low frequency of complications, experience of how to manage them is limited. In this paper, we describe generator- and lead-related complications recorded in a series of S-ICD patients, and we propose our conservative approach to managing them.

METHODS

The study cohort consisted of S-ICD patients who were referred to our institution owing to generator- or lead-related complications requiring surgical intervention. With our "shift and cover" approach, the system component involved is moved from its original position to an alternative, more protected location. In the case of the generator, this involves moving it to an intermuscular pocket. In the case of infections at the parasternal scar, the electrode sleeve is moved away from its original location, stitched, and then covered with the muscular fascia.

RESULTS

Fourteen S-ICD patients were referred to our institution owing to system-related complications. Complications involved the generator in 7 cases (deep pocket infections with erosion, extrusion, or pain), the lead in 5 cases (parasternal infections at the xyphoid incision site), and both the generator and the lead in 2 cases. Complications were managed without completely removing the device and resolved in a single surgical session with no intraoperative complications. During defibrillation testing, the first shock at 65 J was effective in all patients. The shock impedance after revision was significantly lower than that measured during first implantation (59 ± 10 Ohm versus 86 ± 24 Ohm, P = 0.013). In all cases, the cosmetic result was satisfactory. No complications or recurrent infections were reported at the 12-month follow-up visit.

CONCLUSIONS

The proposed conservative approach was successful in managing S-ICD complications. The revision procedure allowed to optimize the system configuration in terms of the defibrillation vector, resulting in lower shock impedance values and better device positioning.

Risk Factors for Mortality in Cardiac Implantable Electronic Device (CIED) Infections: A Systematic Review and Meta-Analysis

Background: Infections following cardiac implantable electronic device (CIED) implantation can require surgical device removal and often results in significant cost, morbidity, and potentially mortality. We aimed to systemically review the literature and identify risk factors associated with mortality following CIED infection. Methods: Electronic searches (up to June 2021) were performed on PubMed and Scopus. Twelve studies (10 retrospective, 2 prospective cohort studies) were included for analysis. Meta-analysis was conducted with the restricted maximum likelihood method, with mortality as the outcome. The overall mortality was 13.7% (438/1398) following CIED infection. Results: On meta-analysis, the male sex (OR 0.77, 95%CI 0.57–1.01, I² = 2.2%) appeared to have lower odds for mortality, while diabetes mellitus appeared to be associated with higher mortality (OR 1.47, 95%CI 0.67–3.26, I² = 81.4%), although these trends did not reach statistical significance. Staphylococcus aureus as the causative organism (OR 2.71, 95%CI 1.76–4.19, I² = 0.0%), presence of heart failure (OR 1.92, 95%CI 1.42–4.19, I² = 0.0%) and embolic phenomena (OR 4.00, 95%CI 1.67–9.56, I² = 69.8%) were associated with higher mortality. Surgical removal of CIED was associated with lower mortality compared with conservative management with antibiotics alone (OR 0.22, 95%CI 0.09–0.50, I² = 62.8%). Conclusion: We identified important risk factors associated with mortality in CIED infections, including Staphyloccocus aureus as the causative organism, and the presence of complications, such as heart failure and embolic phenomena. Surgery, where possible, was associated with better outcomes.