The Burden and Risk Factors for Infection of Transvenous Cardiovascular Implantable Electronic Device: a Nationwide Cohort Study

Early Lead Extraction for Infected Implanted Cardiac Electronic Devices: JACC Review Topic of the Week

Infection remains a serious complication associated with the cardiac implantable electronic devices (CIEDs), leading to substantial clinical and economic burden globally. This review assesses the burden of cardiac implantable electronic device infection (CIED-I), evidence for treatment recommendations, barriers to early diagnosis and appropriate therapy, and potential solutions. Multiple clinical practice guidelines recommended complete system and lead removal for CIED-I when appropriate. CIED extraction for infection has been consistently reported with high success, low complication, and very low mortality rates. Complete and early extraction was associated with significantly better clinical and economic outcome compared with no or late extraction. However, significant gaps in knowledge and poor recommendation compliance have been reported. Barriers to optimal management may include diagnostic delay, knowledge gaps, and limited access to expertise. A multipronged approach, including education of all stakeholders, a CIED-I alert system, and improving access to experts, could help bring paradigm shift in the treatment of this serious condition.

Risk of infective endocarditis associated with invasive dental procedures in patients with cardiac rhythm devices

AIMS

The incidence of infective endocarditis related to cardiac implantable electronic devices (CIEDs) has gradually increased. The risk associated with dental procedures in patients with CIED implantation and the need for prevention of infective endocarditis remain unclear. The present study investigated the incidence and risk of infective endocarditis associated with invasive dental procedures in patients with CIEDs.

METHODS AND RESULTS

We analysed a nationwide population-based cohort of patients with CIEDs who underwent dental procedures. We performed a self-controlled case series analysis and evaluated the incidence rate ratio of infective endocarditis 3 months after dental procedures. Of a total of 62 019 patients who underwent CIED implantation, 32 536 patients underwent at least one dental procedure during follow-up, and the mean number of dental procedures was 3.4 per patient. They were 152 infections with an incidence of 445 per 100 000 person-years in the dental procedure period and 500 events at an incidence of 255 per 100 000 person-years in the non-dental procedure period. The CIED-related infective endocarditis in the dental procedure period occurred significantly more frequently than during non-dental procedure periods (odds ratio, 1.75; 95% confidence interval, 1.48-2.05; P < 0.001). The mean time interval from dental procedure to infective endocarditis was 59.6 ± 47.3 days.

CONCLUSION

Invasive dental procedures are associated with an increased risk of infective endocarditis in those who underwent CIED implantation. Appropriate preventive therapy might be needed in these patients.

Epidemiology of cardiac implantable electronic device infections: incidence and risk factors

Cardiac implantable electronic device (CIED) infection is a potentially devastating complication of CIED procedures, causing significant morbidity and mortality for patients. Of all CIED complications, infection has the greatest impact on mortality, requirement for re-intervention and additional hospital treatment days. Based on large prospective studies, the infection rate at 12-months after a CIED procedure is approximately 1%. The risk of CIED infection may be related to several factors which should be considered with regards to risk minimization. These include technical factors, patient factors, and periprocedural factors. Technical factors include the number of leads and size of generator, the absolute number of interventions which have been performed for the patient, and the operative approach. Patient factors include various non-modifiable underlying comorbidities and potentially modifiable transient conditions. Procedural factors include both peri-operative and post-operative factors. The contemporary PADIT score, derived from a large cohort of CIED patients, is useful for the prediction of infection risk. In this review, we summarize the key information regarding epidemiology, incidence and risk factors for CIED infection.

Comparison of prognosis and safety of pacemaker implantation in patients aged less than or 85 years and older

PURPOSE

Cardiac conduction disturbance necessitating pacemaker implantation is common among elderly patients. However, patients often have comorbidities and increased frailty which may result in limited life prognosis and a high rate of procedure-related complications. We evaluated pacemaker implantation in older patients by comparing life prognosis and complication rate in patients aged ≥ and < 85 years.

METHODS

We retrospectively enrolled 262 consecutive patients who underwent initial pacemaker implantation for bradycardia (age, 77 ± 10 years old; male, 132 (50%); dual chamber pacemaker, 222 (85%) patients). Acute and long-term outcomes were compared between patients aged ≥ 85 and < 85 years. Primary outcome was a composite of all-cause death and severe procedure-related complications.

RESULTS

Seven (14%) patients aged ≥ 85 years (n = 50; 19%) were non-ambulatory. During 2-year follow-up, primary outcome (death or severe complication) occurred in 47 (18%). Freedom from primary outcome was similar between age groups (81.6% versus 80.8%; p = 0.98). Freedom from all-cause death and from severe complication in the study period were also similar (all-cause death, 91.6% versus 88.7%, p = 0.70; severe complication, 89.7% versus 91.5%, p = 0.75). On multivariate analysis, sick sinus syndrome (hazard ratio (HR) 2.7, 95% confidence interval (CI) 1.1-6.4, p = 0.03), immunosuppressant use (HR 21 (95% CI 3.3-134), p < 0.01), and high C-reactive protein (HR 1.5 (95% CI 1.2-1.9), p < 0.01) were independent predictors of primary outcome.

CONCLUSIONS

Life prognosis and severe complication rates after pacemaker implantation were similar between patients aged ≥ and < 85 years.