Low Lead Extraction Rates With Endocarditis Raise Alarm

Relatively few infective endocarditis patients with implanted cardiac devices have their leads extracted as recommended, despite low complication rates, a national study showed.

Transvenous lead extraction occurred in 11.5% of patients with cardiac implantable electronic devices (CIEDs) admitted with endocarditis in the Nationwide Readmissions Database, reported Jim W. Cheung, MD, of Weill Cornell Medicine and NewYork-Presbyterian Hospital in New York City, and colleagues.

That proportion increased significantly over time but remained low, rising from 7.6% in 2016 to 14.9% in 2019 (P<0.001 for trend), they noted in the Journal of the American College of Cardiology.

The alarmingly low rates raise "serious concerns about the management of such patients in real-world clinical practice" and should be a "call to arms" for the field, argued Ayman A. Hussein, MD, of the Cleveland Clinic, and colleagues in an accompanying editorial.

They emphasized and re-emphasized that without "clear prohibitive factors such as terminal illness or patients' preferences of goals of care ... any strategy that does not target complete removal of leads and lead material in CIED-related endocarditis qualifies as suboptimal care."

The study affirmed the known survival advantage of lead removal: Among the 25,303 admissions for patients with CIEDs and endocarditis from 2016 to 2019 in the database, index mortality was 6.0% when managed with lead extraction compared with 9.5% otherwise (P<0.001).

Significant benefits with extraction persisted after adjustment for comorbidities, with an adjusted odds ratio of 0.47 to 0.51 for mortality by multivariable logistic regression or propensity score matching.

This advantage was "almost certainly" understated because the study only looked at inpatient administrative codes, Hussein's group suggested. "In fact, the overall mortality rates in CIED-related infections have been demonstrated to reach 25% to 30%, mostly do not occur during the index hospitalization and typically occur within the year after extraction."

The severity of the clinical scenario appeared to drive decisions to perform extractions, noted the editorialists, pointing to the 3.1-fold higher rate of extraction seen with Staphylococcus aureus infections independent of clinical and hospital characteristics.

"Typically, S. aureus CIED infections lead to a more virulent acute course, which could result in a more definitive management strategy in clinical practice," Hussein's group wrote. "That being said, 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."

Procedural complications of lead extraction were low, at 2.7%. These included vascular complications (superior vena cava injury or repair, innominate vein injury or repair, and other vascular complications), open cardiac surgical repair, hematoma or hemorrhage, cardiac perforation or tamponade, and pneumothorax or hemothorax. Procedural deaths occurred in 0.4%.

"It should be noted that extraction procedures were more likely to be performed in high-volume centers, which could have contributed to the relatively low complication rates," Hussein's group noted. "This emphasizes the need for referral of CIED-related infections to tertiary care centers for extraction and preferably early referrals."

Given the lower mortality in patients with CIEDs and infective endocarditis treated with lead extraction, Cheung and team called for further investigation into barriers to extraction.

Aside from "gaps in physician knowledge" and overestimation of the risks of extraction procedures, the editorialists pointed to lack of access to specialists or centers that perform such procedures as a key barrier.

"The ability of tertiary care centers to accommodate all CIED-related infections may be limited due to the need for special hybrid operating rooms, cardiac surgical backup, and the limited number of specialists who perform extraction procedures," they wrote.

"Building and maintaining lead extraction programs require significant resources; well beyond that of community medical centers," they added. "Improving access may prove challenging in the current healthcare environment with increasing costs and reimbursement cuts, and many fellowship trainees are choosing to not add lead extraction to their skill set. Such issues, among many others, need to be addressed by scientific societies and with regulatory and government agencies."

Meanwhile, physicians should do their part by recognizing CIED-related infections and making early referral, Hussein and colleagues suggested.

Among the 25,303 patients, mean age was 71.2, and 39.5% were women. Compared with patients who did not undergo extraction, those who did were younger (mean age 64.7 vs 72.0), less likely to be women (32.0% vs 40.7%), and more likely to have implantable cardioverter-defibrillators than pacemakers (54.6% vs 32.4%).

The patients who underwent extraction had a higher proportion of hypertension, diabetes, heart failure, coagulopathy, depression, alcohol use disorder, drug abuse, and obesity, while patients who did not had more cerebrovascular disease, dementia, and kidney disease.

Limitations to the study included its observational design, lack of assessment of cause of death, and the inherent flaws of large registry inquiries and use of diagnostic codes without longer duration of follow-up.

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