The use of transvenous lead removal/extraction (TLE) in patients with a cardiac implantable electronic device (CIED) and endocarditis remains low despite a low rate of procedural complications, a study says. Findings that tracked 25,303 admissions for patients with CIEDs and endocarditis reveals that the proportion of patients undergoing TLE management increased from 7.6% in 2016 to 14.9% in 2019. However, only 12% of patients with CIEDs underwent TLE despite the diagnosis of infective endocarditis and low overall rates of TLE-related complications at 2.7%. “Older age, female sex, dementia, cerebrovascular disease, and kidney disease were independently associated with a decreased likelihood of TLE as part of endocarditis management,” said the study, published Monday online and in the May 2 issue of the Journal of the American College of Cardiology. “Concerns about increased risks of TLE in patients with high comorbidity burden or poor prognosis may have guided decisions not to perform TLE.” Further findings by the U.S.-based researchers linked the presence of International Classification of Diseases (ICD), Staphylococcus aureus infection, and larger hospital size with increased TLE management. After adjustment for comorbidities, TLE was associated with significantly lower all-cause mortality following admission for endocarditis in the presence of a CIED. This reduction was particularly pronounced among patients with S. aureus infections, said the study, led by Christopher T. Sciria, MD, from the Weill Cornell Medicine–New York Presbyterian Hospital. Study details The research team obtained admission data from the Nationwide Readmissions Database (NRD) of 25,303 patients with CIEDs and endocarditis between January 2016 and November 2019. The team also identified hospitalizations with concomitant S. aureus infections. The overall population had a mean age of 71.2 ± 0.2 years and 39.5% of patients were female . The primary endpoint of the study was index mortality, defined as in-hospital mortality during index admission for infective endocarditis in presence of existing CIED. Results revealed that among admissions for patients with CIEDs and endocarditis, 2,900 (11.5%) were managed with TLE with the proportion undergoing TLE significantly increasing from 2016 to 2019 (7.6% vs 14.9%; P trend <0.001). Procedural complications were identified in 2.7% of the sample population, with index mortality significantly lower among patients managed with TLE (6.0% vs 9.5%; P <0.001). After adjustment for comorbidities, TLE was independently associated with significantly lower odds of mortality (adjusted odds ratio [OR]: 0.47; 95% confidence interval [CI]: 0.37-0.60 by multivariable logistic regression and adjusted OR: 0.51; 95% CI: 0.40-0.66 by propensity score matching). HRS consensus statement In commenting on the low rates of device extraction with CIED-associated infections, the study cited the 2017 Heart Rhythm Society (HRS) consensus statement advising that the presence of endocarditis was an indication for CIED removal with or without clear evidence of CIED infection. “Our study identified a significant linear increase in the proportion of patients with CIEDs and infective endocarditis undergoing TLE between 2016 and 2019,” the research team said. “Whether or not the publication of the HRS consensus statement on CIED lead management and extraction in 2017 altered physician practice patterns is unclear.” On the reduction of mortality associated with CIED-associated endocarditis managed with lead extraction, the team noted its findings were consistent with established literature that complete CIED system removal was required for successful treatment of CIED-associated infections. Commenting on the impact of ICDs, S. aureus infection, and large hospital size, the researchers suggested that increased identification of vegetation on ICD leads and detection of pocket infection were likely to trigger the decision to pursue ICD system removal. “S. aureus infection may be associated with a more virulent clinical course with pronounced microbiological and imaging findings, which would likely lead to physician decision to proceed to lead extraction,” the team added. “A large hospital size is likely associated with increased access to physician expertise and equipment for lead extraction. This would suggest that patient access to lead extraction centers can have a significant impact on outcomes.” ‘A call to arms’ In an editorial comment on this point, Ayman A. Hussein, MD, Oussama M. Wazni, MD, and Bruce L. Wilkoff, MD, from the Cleveland Clinic, said that this emphasizes the need for referral – preferably early – of CIED-related infections to tertiary-care centers for extraction. “In fact, it has been reported that delayed lead extraction in patients with CIED-related infection is associated with increased in-hospital mortality and major adverse events, especially in patients with systemic infection,” they added. The authors also highlighted that typically, S. aureus CIED infections led to a more virulent acute course, which could result in a more definitive management strategy in clinical practice. It is important to emphasize that confirmed CIED-related infections, especially with endocarditis, should be managed with complete removal of the device and hardware, regardless of culprit pathogens or the severity of the clinical scenario, they said. “Unless there are clear prohibitive factors such as terminal illness or patients’ preferences of goals of care, no other strategies should be acceptable for the management of patients with CIEDs and infective endocarditis,” the authors concluded. “The investigators should be congratulated on their efforts and for raising awareness about this issue: This is a call to arms.” Sources: Sciria CT, Kogan EV, Mandler AG, et al. Low Utilization of Lead Extraction Among Patients With Infective Endocarditis and Implanted Cardiac Electronic Devices. J Am Coll Cardiol. 2023;81:1714–1725. Hussein AA, Wazni OM, Wilkoff BL. Cardiac Implantable Electronic Devices and Infective Endocarditis: A Call to Arms. J Am Coll Cardiol. 2023;81:1726 – 1728. 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