The influence of prolonged antibiotic treatment before lead extraction procedures on the outcomes of device reimplantation in cardiac implantable electronic device infections
Authors: Pavlenko T , Valente B , Santos H , Lousinha A , Cunha P , Portugal G , Osorio P , Bongiorni M , Oliveira M 
Published: October 2024

Abstract

Background
Cardiac implantable electronic devices (CIED) related infections have a considerable clinical and economic burden in the cohort of CIED-implanted patients and require a complex and thoughtful approach of the "heart team". Complete CIED removal is recommended for all patients with confirmed CIED infection, but the optimal duration of antibiotic therapy (AT) before lead extraction (LE) and its impact on the time of reimplantation are still debatable [1-2]. This study was aimed to evaluate the impact of prolonged AT before LE on the outcomes of device reimplantation.

Methods
Consecutive cases of LE due to CIED infection at our centre from 2013 to 2022 were reviewed. Our approach assumed the duration of AT for a minimum of 2 weeks for patients with pocket infection (PI), and at least 4 weeks for endocarditis with the exception of non-response to the AT. The target time for reimplantation was 2-3 days after LE with the exception of uncontrolled infection, positive blood culture, logistical reasons or reevaluation of pacing indications during follow-up.

Results
From a total of 256 LE, 202 (in 198 patients) were due to CIED infection (pacemaker-67,8%, CRT-19,8%, ICD-12,4%). In 62,4% of the cases there was only PI, in 24,7% only endocarditis and in 12,9% it was concomitant. Systemic infection was found in 43,1% of the cases. The mean dwell time of the leads was 92.2±5.0 months (n=201, median 84, IQR 29.0-132.0). In cases of PI, the mean time of AT before LE was 21,7±1,0 days (n=124, median 21, IQR 14.0-28.0), whereas it was 31,6±1,7 days (n=76, median 28, IQR 21.0-42.0) in cases of endocarditis (p&lt;0.05). The duration of AT after LE was 17.7±0.8 days (n=121, median 14, IQR 14.0-21.0) in cases of PI and 22.7±1.4 days (n=76, median 21, IQR 14.0-28.0) in cases of endocarditis (p&lt;0.05). Procedural success was achieved in 98,5% and the procedural failure rate was 1,5%. Major complication rate was 2,5% and minor complication rate was 8,9%. There was no intraprocedural death. Device reimplantation after LE was performed in 68,8% (139) of all patients. The majority of reimplantations (57,6%) occurred within 7 days after LE (figure 1). The mean reimplantation time was 43.6±12.1 days (n=135, median 6, IQR 4.0-15.0), without statistically significant difference in time to reimplantation between PI and endocarditis (p=0.78). 9 patients were reimplanted with epicardial ventricular lead and 1 with leadless pacemaker. Total reinfection rate was 2% (4), all the cases were due to contralateral PI with reimplantation after LE in 11, 12, 38 and 596 days, respectively. One of the patients was also diagnosed with an allergy to silicone, nickel and palladium. Mortality rate during the first 30 days was 5%. Uneventful 12-month follow-up was achieved by 80,2%.

Conclusions
Appropriate prolonged AT before LE led to feasibility of early device reimplantation with a low rate of reinfection.Time to preimplantation