Early lead extraction and outcomes of cardiac implantable electronic device-related infective endocarditis

Abstract Background Complete removal of a cardiac implantable electronic device (CIED) is a class Ⅰ recommendation for managing CIED infection, but few large studies have investigated current practice patterns and outcomes of CIED-related infective endocarditis (CDRIE). Purpose The purpose of our study was to investigate the occurrence of CDRIE and clarify the association between early lead extraction and outcomes in patients with CDRIE. Methods We extracted patients who underwent CIED implantation or generator replacement between 2013 and 2019 using a Japanese nationwide health insurance claims database covering almost all of the Japanese population. The incidence of CDRIE was assessed. We excluded patients who underwent open valvular surgery and analyzed the association between the lead extraction within 30 days of the first CDRIE admission and all-cause mortality using propensity score matching with a 30-day landmark analysis. Results Among 552,849 patients undergoing CIED procedures, 2,368 developed a CDRIE. Of 1,839 patients who met inclusion criteria and were alive at 30 days of admission, 334 (18.2%) patients underwent lead extraction within 30 days. The median (interquartile range) was 494 (145–1093) days. Patients who underwent lead extraction within 30 days were younger, had a lower proportion of females, a higher proportion of ICD or CRT devices, were more frequently admitted to facilities available for transvenous lead extraction, and had shorter intervals since their last CIED implantation compared to those without lead extraction within 30 days. After propensity score matching, 295 patients were analyzed in each group. Lead extraction within 30 days of admission was associated with a lower risk of mortality compared to no early extraction (hazard ratio, 0.60: 95% CI, 0.45–0.80; P 0.001). Conclusion The proportion of early lead extraction for CDRIE was low in current clinical practice. Our findings suggest a need to increase the proportion of guideline-based care among patients with CDRIE.