Infection and infective endocarditis according to type of diabetes mellitus after cardiac implantable electronic device implantation: a contemporary nationwide cohort study

Background

Patients with diabetes mellitus (DM) are at increased risk of infection. However, there are controversial reports about type 1 or 2 DM and their associations with infection and infective endocarditis (IE) following implantation of cardiac implantable electronic device (CIED). We evaluated the contemporary incidence of infections and infective endocarditis (IE) following implantation of a first-time, permanent CIED in DM patients compared to controls.

Methods

This French longitudinal cohort study was based on the national hospitalization database covering hospital care from for the entire population. All adults hospitalized in French hospitals from 2010 to 2019, who underwent a de novo permanent pacemaker (PM) or implantable cardioverter defibrillator (ICD) implantation were identified together with the occurrence of post-implantation infection and IE-events during follow-up.

Results

In total 688,007 CIED patients were identified (pacemakers 87.3%, ICDs 12.7%). History of diabetes was present in 162,490 patients: 8,041 (1.2%) with type 1 DM and 154,449 (22.5%) with type 2 DM. Patients with no DM were slightly older and had less prevalent associated comorbidities than those with DM. Patients with type 1 DM had less prevalent associated comorbidities than those with type 2 DM. Follow-up was 2.6±2.6 years (median 1.9, IQR 0.2–4.3 years). There were 9,804 patients with CIED-related infection during follow-up (incidence rate 5.48 per 1000 patient.year) among whom 2,658 had IE (incidence rate 1.49 per 1000 patient year).

The incidence rate (per 1000 PYs) of CIED-related infection and IE in the different subgroups of patients with no DM, type 1 DM and type 2 DM are in Table 1. Incidence rates were higher in patients with DM than in those with no DM, and numerically higher in those with type 2 DM than in those with type 1 DM.

In multivariable analysis (adjustment on baseline characteristics including age, cardiovascular and non-cardiovascular comorbidities and type of CIED), type 1 DM and type 2 DM were independent risk factors for CIED-related infection vs no DM. Type 1 DM was not associated with a statistically different risk of CIED-related infection than type 2 DM.

When analysing the risk of IE during FU, type 2 DM was an independent risk factors for IE vs no DM, whilst there was a non-statistical trend for type 1 DM vs no DM. Type 1 DM was however not associated with a statistically different risk of IE than type 2 DM. Results were similar when one considered separately the periods 2010–2014 and 2015–2019

Conclusion

The risk of CIED-related infection was significantly higher in patients with type 1 and type 2 DM than in those with no DM. Although there were differences in the profile and clinical history of patients with type 1 and type 2 DM, there was no statistical difference in the risk of CIED-related infection and IE in patients with type 1 and type 2 DM in this contemporary analysis at a nationwide level.

Funding Acknowledgement

Type of funding sources: None.

Infection and infective endocarditis after cardiac implantable electronic device implantation: a contemporary nationwide cohort study

Funding Acknowledgements

Type of funding sources: None.

Aims

To determine the contemporary incidence and risk factors of infection and infective endocarditis (IE) following implantation of a first-time, permanent, cardiac implantable electronic device (CIED).

Methods

This French longitudinal cohort study was based on the national hospitalization database covering hospital care from for the entire population. All adults (age ≥18 years) hospitalized in French hospitals from January 1, 2010 to December 31, 2019, who underwent a de novo permanent pacemaker (PM) or implantable cardioverter defibrillator (ICD) implantation were identified together with the occurrence of post-implantation infection and IE-events during follow-up.

Results

In total 688,007 CIED patients with de novo implants were identified (single-chamber pacemaker 18.8%, dual-chamber pacemaker 64.9%, cardiac resynchronization therapy [CRT]pacemaker 3.2%, single-chamber ICD 4.3%, dual-chamber ICD 3.4%, CRT ICD 5.5%). Follow-up was 2.6±2.6 years (median 1.9, IQR 0.2-4.3 years) and total follow-up time was 1,788,166person-years (PYs). There were 9,804 patients with CIED-related infection during follow-up (incidence rate 5.48 per 1000 patient.year) among whom 2,658 had IE (incidence rate 1.49 per 1000 patient.year).

The incidence rate (per 1000 PYs) of CIED-related infection and IE in the different subgroups of patients with pacemakers and ICD (single-chamber, dual-chamber, CRT) are in table 1. Incidence rates were higher in patients with an ICD than in those with a pacemaker, and higher in those with CRT. Incidence rates of CIED-related infection and IE were not different in single-chamber vs dual-chamber CIEDs(table 1).

In multivariable analysis, ICD (vs pacemaker, HR: 1.59; 95% CI 1.40-1.80) and CRT (vs no CRT, HR: 1.21; 95% CI: 1.07-1.37) were independent risk factors for CIED-related infection. Dual-chamber pacemakers were not associated with a higher risk of CIED-related infection than single-chamber pacemakers. Similarly, dual-chamber ICDs were not associated with a higher risk of CIED-related infection than single-chamber ICDs (table). There were similar findings when analysing the risk of IE during FU. ICD (vs pacemaker, HR: 1.31; 95% CI 1.23-1.40) and CRT (vs no CRT, HR: 1.24; 95% CI: 1.16-1.32) were independent risk factors for IE. Dual-chamber pacemakers were not associated with a higher risk of IE than single-chamber pacemakers and dual-chamber ICDs were not associated with a higher risk of IE than single-chamber ICDs (table).

Results were similar when one considered separately the periods 2010-2014 and 2015-2019

Conclusion

The risk of CIED-related infection and IE was significantly higher in patients with ICDs than in those with pacemakers and significantly higher with CRT than with no CRT. By contrast, there was no statistical difference in the risk of CIED-related infection and IE in patients with single-chamber or dual-chamber CIEDs in this contemporary analysis at a nationwide level.

Clinical outcomes associated with left atrial appendage occlusion via implanted device in atrial fibrillation:a Nationwide Matched Control Study

Funding Acknowledgements

Type of funding sources: None.

Introduction / Background

Left atrial appendage occlusion (LAAO) has emerged as a nonpharmacological alternative for stroke prevention in patients with atrial fibrillation (AF). Contemporary data regarding the characteristics and outcomes of patients undergoing this procedure compared to a control group not treated with LAAO are limited.

Purpose

Our objective was to compare outcomes following first LAAO implantation in an exhaustive nationwide matched cohort.

Methods

This French longitudinal cohort study was based on the national hospitalization database covering hospital care from for the entire population. All adults (age ≥18 years) hospitalized in French hospitals with AF from January 1, 2015 to January 1, 2020, who underwent a LAAO implantation were identified. Owing to the non-randomized nature of the study, and considering for significant differences in baseline characteristics between AF patients treated with LAAO and no LAAO, propensity-score matching was used to control for potential confounders of the treatment outcome relationship. The primary outcome was a composite of ischemic stroke, major bleeding (Bleeding Academic Research Consortium ≥3) or all-cause mortality during follow-up.

Results

After propensity score matching 2,682 patients with LAAO were matched 1:1 with 2,682 AF patients not treated with LAAO. Baseline characteristics of matched patients are illustrated in Figure 1. Mean follow-up was 7 months (median 5, interquartile 1-11 months). As illustrated in Figure 2, AF patients treated with LAAO had a significantly lower risk of the primary composite outcome as compared with patients not treated with LAAO (hazard ratio [HR] 0.59, 95% confidence interval [CI]: 0.52 to 0.68). Total events and event rates per 100 patient-years were (LAAO vs. no LAAO) 315 vs. 591 and 20.6%/year vs. 36.1%/year, respectively. The risk of ischemic stroke was comparable between groups (HR 1.06, 95% CI: 0.75 to 1.17), while risk of major bleeding (HR 0.49, 95% CI: 0.37 to 0.65) and all-cause mortality (HR 0.57, 95% CI: 0.48 to 0.67) were significantly lower in patients treated with LAAO.

Conclusion

Among AF patients with a high risk of bleeding, our nationwide study highlighted a high risk of clinical events during follow-up. Patients treated with LAAO may have similar stroke prevention efficacy but lower risk of major bleeding and mortality when compared to propensity score-matched patients not treated with LAAO.

Futility risk model for predicting outcome after cardiac resynchronization therapy defibrillator implantation: data from a nationwide analysis

Funding Acknowledgements

Type of funding sources: None.

Objective. Risk-benefit assessment for cardiac resynchronization therapy defibrillator (CRT-D) over a CRT pacemaker (CRT-P) is still a matter of debate. We aimed to identify patients with a bad outcome within one year after CRT-D implantation, and to develop a Futile CRT-D score.

Methods. Based on the administrative hospital-discharge database, all consecutive patients treated with CRT-D implantation in France between 2010 and 2019 were included. A prediction model was derived and validated for one-year all-cause death after CRT-D implantation (considered as futility) by using split-sample validation.

Results. 28,503 patients were included in the analysis (mean age 68 ± 10 years); 2,139 (7.5%) deaths were recorded in the first year. In the derivation cohort (n = 14,252), the final logistic regression model included as main predictors of futility older age, diabetes, mitral regurgitation, history of hospital stay with heart failure, history of pulmonary oedema, atrial fibrillation, renal, pulmonary, liver, or thyroid disease, denutrition and anemia. Based on Futile CRT-D score, 17% of these patients were categorized at high risk (Futile CRT-D score ≥13) and predicted futility at 17%.

Conclusion.  The futility CRT-D score, established from a large nationwide cohort of patients treated with CRT-D may provide a relevant tool for optimizing healthcare decision. Death at one year in patients with CRTD OR (95%CI)pPointsAge (quartile)1.353 (1.266-1.446)<0.00012Diabetes mellitus1.413 (1.225-1.629)<0.00012Heart failure with congestion1.908 (1.501-2.423)<0.00013History of pulmonary edema1.445 (1.194-1.749)<0.00012Mitral regurgitation1.259 (1.074-1.475)0.0042Atrial fibrillation1.601 (1.395-1.838)<0.00012Left BBB0.803 (0.698-0.924)0.002-1Dyslipidemia0.809 (0.696-0.940)0.006-1Denutrition1.709 (1.360-2.147)<0.00012Chronic kidney disease1.574 (1.321-1.875)<0.00012Lung disease1.230 (1.052-1.437)0.0092Sleep apnea syndrome0.740 (0.596-0.919)0.007-1Liver disease1.747 (1.384-2.206)<0.00012Anaemia1.325 (1.105-1.589)0.0022BBB = bundle branch block.; * age quartile: 1 point when age >61, 2 points when age >69, 3 points when age >75.Abstract Figure. AUC and incidences of all-causes death

[Prognostic elements at early stapes of severe spinal cord injuries (value of pain sensitivity]

The prognosis in serious spinal cord injury remains difficult. The neurologist has a large number of elements at his disposal, but their reliability is uncertain. Clinical information, experimental work and recent data on medullar vascularization makes it possible to isolate diagramatically in the spinal cord a medium layer which contains the pyramidal and spino-thalamic tracts. The neighbourhood of these two fasciculi confers them a similar vulnerability to severe injury. Thus when an injured tetraplegic or paraplegic patient recovers his sensitivity to pain, he finally must recover his motor function and on the contrary, the recovery of motility is impossible without a return of pain sens. Clinical observation is in consequence of major importance as it shows that the recovery of sensitivity to pain, in the case of a patient with a serious spinal cord injury, is an argument for a favourable prognosis, whereas the recovery of an isolated tact perception does not in itself makes it possible to hope for eventual recovery of motor power.