Leadless pacing in patients undergoing transvenous lead extraction due to infection: A small step in a long journey

Abstract

Improvement in technology and the expansion of indications have led to a progressive increase in the implantation of cardiovascular implantable electrical devices (CIED). This trend is accompanied by a rise in CIED related complications, in particular device related infections (DRI) which are associated with a significant impact on patient prognosis and healthcare associated costs. 1 Voigt A Shalaby A Saba S Rising rates of cardiac rhythm management device infections in the United States: 1996 through 2003. Journal of the American College of Cardiology. Aug 1 2006; 48: 590-591 Google Scholar ,2 Diemberger I Segreti L Rinaldi CA Svendsen JH Kutarski A Younis A Laroche C Leclercq C Małecka B Mitkowski P Bongiorni MG On Behalf Of The EI. 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. Biology Apr. 2022; 18: 11 Google Scholar In the case of DRI, current guidelines give a class I indication to complete system removal using transvenous lead extraction (TLE) approach. 3 Kusumoto FM, Schoenfeld MH, Wilkoff BL, et al. 2017 HRS expert consensus statement on cardiovascular implantable electronic device lead management and extraction. Heart Rhythm Dec 2017;14:e503-e551. Google Scholar Until recent years most of the focus of the management of DRI was related to the TLE procedure itself. Physicians, researchers, and the industry have all invested tremendous resources into improving the peri-procedural outcomes, aiming to increase the success rate as well as to decrease the complexity of the procedure. In addition, efforts were made to reduce the rate of DRI and implantation complications. 4 Tarakji KG Mittal S Kennergren C et al. Antibacterial Envelope to Prevent Cardiac Implantable Device Infection. The New England journal of medicine. May 16 2019; 380: 1895-1905 Google Scholar However, little has been done to optimize the post-procedural coarse following TLE, especially in DRI patients. Recent literature has shown that, while the timing of TLE and the periprocedural outcomes are of significant relevance for prognosis, post-procedure mortality remains several times higher than procedure-related mortality, reaching 30% at 1 year post TLE in DRI patients. 5 Narui R Nakajima I Norton C et al. Risk Factors for Repeat Infection and Mortality After Extraction of Infected Cardiovascular Implantable Electronic Devices. JACC Clinical electrophysiology Sep. 2021; 7: 1182-1192 Google Scholar , 6 Lee JZ Tan MC Karikalan S et al. Causes of Early Mortality After Transvenous Lead Removal. JACC Clinical electrophysiology. Dec 2022; 8: 1566-1575 Google Scholar , 7 Younis A Beinart R Nehoray N Asher E Matetzky S Beigel R Wieder A Glikson M Nof E Characterization of a previously unrecognized clinical phenomenon: Delayed shock after cardiac implantable electronic device extraction. Heart Rhythm. Oct 2017; 14: 1552-1558 Google Scholar This information has a significant impact on post-TLE management, including reimplantation strategies. The timing of re-implantation becomes even more challenging in patients who are pacing dependent, those with cardiac resynchronization therapy (CRT), and those with secondary prevention defibrillators with increased risk of ventricular tachyarrhythmias and sudden cardiac death. In the setting of DRI, the optimal timing of CIED-reimplantation for these patients after a successful TLE is currently unknown. Concomitant leadless pacing in pacemaker-dependent patients undergoing transvenous lead extraction for active infection: Mid-term follow-upHeart RhythmPreviewThe rate of transvenous lead extraction (TLE) due to cardiac implantable electronic device (CIED) infection continues to rise. CIED infections are associated with significant morbidity and mortality. Temporary pacing in patients with active CIED infections after TLE can be challenging. Leadless pacing has emerged as an alternative approach in this patient population. Full-Text PDF