Heart failure is associated with increased risk of all-cause mortality after transvenous lead extraction: A systematic review and meta-analysis

Background

Transvenous lead extraction (TLE) is increasingly considered in cardiac implantable electronic device management. Heart failure (HF) might be associated with mortality risks after the TLE procedure. This study aims to assess mortality risk in HF patients undergoing TLE.

Method

We searched MEDLINE and Embase databases from inception to June 2022 to identify articles that included patients with and without HF who underwent TLE, which reported mortality in both groups. The pooled effect size was calculated with a random-effects model and 95% CI to compare post-TLE mortality between the two groups.

Results

Eleven studies were included in the analysis. Each left ventricular ejection fraction (LVEF) increased by 1% was associated with reduced mortality by 2% (HR = 0.98, 95% CI: 0.97-0.99, I 2 = 74.9%, p < .01). The presence of HF compared to those without HF was associated with higher mortality rates (OR: 3.04, 95% CI: 2.56-3.61, I 2 = 0.0%, p < .531). There was a significant increase in the mortality rates in patients with New York Heart Association (NYHA) function class III (OR: 2.29, 95% CI: 1.29-4.06, I 2 = 0.0%, p = .498) and NYHA IV (OR: 8.5, 95% CI: 2.98-24.3, I 2 = 0.0%, p = .997).

Conclusions

Our study found that post-TLE mortality decreases by 2% as LVEF increases by 1%, also mortality is higher in patients with NYHA III and IV.

Chronic kidney disease is associated with increased all-cause mortality in transvenous lead extraction: A systematic review and meta-analysis

BACKGROUND

The impact of chronic kidney disease (CKD) or end-stage renal disease (ESRD) on patients receiving transvenous lead extraction (TLE) is not well-established. We performed a systematic review and meta-analysis to explore the association between CKD and all-cause mortality in TLE.

METHODS

We searched the databases of PubMed and EMBASE from inception to April 2022. Included studies were published TLE studies that compared the risk of mortality in CKD patients compared to control patients. Data from each study were combined using the random-effects model.

RESULTS

Eight studies (5,013 patients) were included. Compared with controls, CKD patients had a significantly higher risk of overall all-cause mortality (hazard ratio [HR] = 2.14, 95% confidence interval [CI]: 1.65-2.77, I²  = 51.1%, p < .001). The risk of overall all-cause mortality increased with the severity of CKD for nonspecific CKD (HR = 2.01, 95% CI: 1.49-2.69, I²  = 53.4, p < .001) and ESRD (HR = 2.79, 95% CI: 1.85-4.23, I²  = 0%, p < .001). The risk of all-cause mortality in CKD is double at follow-up ≤1 year (HR = 1.99, 95% CI: 1.29-3.09, I²  = 50.9%, p = .002) and higher at follow-up >1 year (HR = 2.36, 95% CI: 1.63-3.42, I²   = 59.7%, p < .001).

CONCLUSIONS

Our meta-analysis demonstrates a significantly increased risk of overall all-cause mortality in patients with CKD who underwent TLE compared to controls.

Causes of Early Mortality After Transvenous Lead Removal

BACKGROUND

Recognition of the causes of early mortality (≤30 days) after transvenous lead removal (TLR) is an essential step for the development of quality improvement programs.

OBJECTIVES

This study sought to determine the causes of early mortality after TLR and to further understand the circumstances surrounding death after TLR.

METHODS

A retrospective analysis was performed of all patients undergoing TLR from January 1, 2001, to January 1, 2021, at the Mayo Clinic (Rochester, Minnesota; Phoenix, Arizona; and Jacksonville, Florida). Causes of death were identified through a detailed chart review of the electronic health record from within the Mayo Clinic system and outside records when available. The causes of death were further characterized based on whether it was related to the TLR procedure.

RESULTS

A total of 2,319 patients were included in the study. The overall 30-day all-cause mortality rate was 3% (n = 69). Among all 30-day deaths, infection was the most common primary cause of death (42%). This was followed by decompensated heart failure (17%), procedure-related death (10%), sudden cardiac arrest (7%), and respiratory failure (6%). The 30-day mortality rate directly due to complications associated with the TLR procedure was 0.3%. One-third of deaths (33%) occurred after discharge from the index hospitalization; among these, 43% were readmitted before their death, 35% died at home or at a nursing facility, and 22% were discharged on comfort care and died in hospice. The main reasons for readmission before death were sepsis and decompensated heart failure.

CONCLUSIONS

The majority (90%) of 30-day mortality after TLR was not due to complications associated with TLR procedures. The primary causes were infection and decompensated heart failure. This highlights the importance of increased emphasis on postprocedure management of infection and heart failure to reduce postoperative mortality, including after hospital discharge.

Step by Step through the Years-High vs. Low Energy Lead Extraction Using Advanced Extraction Techniques

Background: Limited data is available about the outcome of TLE in patients with vs. without high energy leads in the last decade. Methods: This is an analysis of consecutive patients undergoing TLE at a high-volume TLE centre from 2001 to 2021 using the stepwise approach. Baseline characteristics, procedural details and outcome of patients with high energy lead (ICD group) vs. without high energy lead (non-ICD group) were compared. Results: Out of 667 extractions, 991 leads were extracted in 405 procedures (60.7%) in the ICD group and 439 leads in 262 procedures (39.3%) in the non-ICD group. ICD patients were significantly younger (median 67 vs. 74 years) and were significantly less often female (18.1% vs. 27.7%, p < 0.005 for both). Advanced extraction tools were used significantly more often in the ICD group (73.2% vs. 37.5%, p < 0.001), but there were no significant differences in the successful removal (98.8% vs. 99.2%) or complications (4.7% vs. 3.1%) between the groups (p > 0.2 for both). Discussion: Using the stepwise approach, overall procedural success was high and complication rate was low in a high-volume centre. In patients with a high energy lead, the TLE procedure was more complex, but outcome was similar to comparator patients.

Assessing long-term survival and hospitalization following transvenous lead extraction in patients with cardiac resynchronization therapy devices: A propensity score-matched analysis

Background

Longer-term outcomes of patients post transvenous lead extraction (TLE) are poorly understood in patients with cardiac resynchronization therapy (CRT) devices.

Objectives

A propensity score (PS)–matched analysis evaluating outcomes post TLE in CRT and non-CRT populations was performed.

Methods

Data from consecutive patients undergoing TLE between 2000 and 2019 were prospectively collected. Patients surviving to discharge and reimplanted with the same device were included. The cohort was split depending on presence of CRT device. Associations with all-cause mortality and hospitalization were assessed by Kaplan-Meier estimates. An exploratory endpoint was evaluated whether early (<7 days) or late (>7 days) reimplantation was associated with poorer outcomes.

Results

Of 1005 patients included, 285 (25%) had a CRT device. Median follow-up was 57.00 [27.00–93.00] months, age at explant was 67.7 ± 12.1 years, 83.3% were male, and 54.4% had an infective indication for TLE. PS was calculated using 43 baseline characteristics. After matching, 192 CRT patients were compared with 192 non-CRT patients. In the matched cohort, no significant difference with respect to mortality (hazard ratio [HR] = 1.01, 95% confidence interval [CI] [0.74–1.39], P = .093) or hospitalization risk (HR = 1.2, 95% CI [0.87–1.66], P = .265) was observed. In the matched CRT group, late reimplantation was associated with increased mortality (HR = 1.64, [1.04–2.57], P = .032) and hospitalization risk (HR = 1.57, 95% CI [1.00–2.46], P = .049].

Conclusion

Outcomes of CRT patients post TLE are similarly as poor as those of non-CRT patients in matched populations. Reimplantation within 7 days was associated with better outcomes in a CRT population but was not observed in a non-CRT population, suggesting prolonged periods without biventricular pacing should be avoided.

Prognosis of patients with severe left ventricular dysfunction after transvenous lead extraction and the need for additional hemodynamic support in the perioperative period

BACKGROUND

Transvenous lead extraction (TLE) is necessary because of system infection, lead malfunction, or system upgrade. Patients with severe left ventricular dysfunction (SLVD) undergoing TLE may be at a higher risk because hemodynamic parameters may change unfavorably during or after TLE; however, this has not yet been clarified.

OBJECTIVE

The purpose of this study was to examine whether patients with SLVD undergoing TLE have higher mortality.

METHODS

All patients who underwent TLE were stratified as follows: patients with ejection fraction ≤ 35% (SLVD group) and those with ejection fraction > 35% (non-SLVD group).

RESULTS

We assessed the data of 200 patients [SLVD group, 36 (18%); non-SLVD group, 164 (82%)]). Brain natriuretic peptide level and cardiac resynchronization therapy rate were higher in the SLVD group than in the non-SLVD group. There were no significant between-group differences in major complications and clinical success rates. Patients with SLVD were more likely to require additional hemodynamic support, such as catecholamine infusion, temporary atrium-ventricle sequential pacing, and temporary cardiac resynchronization therapy pacing (27.8% vs 1.2%; P < .001). The survival rate was not significantly different between the groups at 30 days and 1 year after TLE (SLVD vs non-SLVD: 30 days: 97.2% vs 99.4%; P = .215; 1 year: 80.6% vs 91.5%; P = .053). Multivariate Cox regression analysis revealed log brain natriuretic peptide and serum hemoglobin levels as predictors for 1-year mortality.

CONCLUSION

The prognosis after TLE was comparable between patients with and without SLVD. However, additional hemodynamic support was often necessary for patients with SLVD.

The effect of centre volume and procedure location on major complications and mortality from transvenous lead extraction: an ESC EHRA EORP European Lead Extraction ConTRolled ELECTRa registry subanalysis

Aims 

Transvenous lead extraction (TLE) should ideally be undertaken by experienced operators in a setting that allows urgent surgical intervention. In this analysis of the ELECTRa registry, we sought to determine whether there was a significant difference in procedure complications and mortality depending on centre volume and extraction location.

Methods and results 

Analysis of the ESC EORP European Lead Extraction ConTRolled ELECTRa registry was conducted. Low-volume (LoV) centres were defined as &lt;30 procedures/year, and high-volume (HiV) centres as ≥30 procedures/year. Three thousand, two hundred, and forty-nine patients underwent TLE by a primary operator cardiologist; 17.1% in LoV centres and 82.9% in HiV centres. Procedures performed by primary operator cardiologists in LoV centres were less likely to be successful (93.5% vs. 97.1%; P &lt; 0.0001) and more likely to be complicated by procedure-related deaths (1.1% vs. 0.4%; P = 0.0417). Transvenous lead extraction undertaken by primary operator cardiologists in LoV centres were associated with increased procedure-related major complications including death (odds ratio 1.858, 95% confidence interval 1.007–3.427; P = 0.0475). Transvenous lead extraction locations varied; 52.0% operating room, 9.5% hybrid theatre and 38.5% catheterization laboratory. Rates of procedure-related major complications, including death occurring in a high-risk environment (combining operating room and hybrid theatre), were similar to those undertaken in the catheterization laboratory (1.7% vs. 1.6%; P = 0.9297).

Conclusion 

Primary operator cardiologists in LoV centres are more likely to have extractions complicated by procedure-related deaths. There was no significant difference in procedure complications between different extraction settings. These findings support the need for TLE to be performed in experienced centres with appropriate personnel present.

Financial and resource costs of transvenous lead extraction in a high-volume lead extraction centre

OBJECTIVES

Transvenous lead extraction (TLE) poses a significant economic and resource burden on healthcare systems; however, limited data exist on its true cost. We therefore estimate real-world healthcare reimbursement costs of TLE to the UK healthcare system at a single extraction centre.

METHODS

Consecutive admissions entailing TLE at a high-volume UK centre between April 2013 and March 2018 were prospectively recorded in a computer registry. In the hospital's National Health Service (NHS) clinical coding/reimbursement database, 447 cases were identified. Mean reimbursement cost (n=445) and length of stay (n=447) were calculated. Ordinary least squares regressions estimated the relationship between cost (bed days) and clinical factors.

RESULTS

Mean reimbursement cost per admission was £17 399.09±£13 966.49. Total reimbursement for all TLE admissions was £7 777 393.51. Mean length of stay was 16.3±15.16 days with a total of 7199 bed days. Implantable cardioverter-defibrillator and cardiac resynchronisation therapy defibrillator devices incurred higher reimbursement costs (70.5% and 68.7% higher, respectively, both p<0.001). Heart failure and prior valve surgery also incurred significantly higher reimbursement costs. Prior valve surgery and heart failure were associated with 8.3 (p=0.017) and 5.5 (p=0.021) additional days in hospital, respectively.

CONCLUSIONS

Financial costs to the NHS from TLE are substantial. Consideration should therefore be given to cost/resource-sparing potential of leadless/extravascular cardiac devices that negate the need for TLE particularly in patients with prior valve surgery and/or heart failure. Additionally, use of antibiotic envelopes and other interventions that reduce infection risk in patients receiving transvenous leads should be considered.