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Prognosis associated with redo cardiac resynchronization therapy following complete device and lead extraction due to
Martin Seifert1, Viviane Moeller1, Anita Arya2
1Department of Cardiology, Heart Center Brandenburg, Bernau/Berlin, and Medical School Brandenburg, Germany.
Insights
Redo cardiac resynchronization therapy (CRT) implantation after device infection has a low success rate and increased re-infection risk. Staphylococcus aureus infections are linked to poorer outcomes in patients undergoing redo CRT procedures.
Area of Science:
- Cardiology
- Medical Devices
- Infectious Diseases
Background:
- Cardiac resynchronization therapy (CRT) device implantations are increasing globally.
- Device-related infections necessitate CRT device extraction, posing challenges for subsequent reimplantation.
- Redo CRT implantation requires careful evaluation of success rates and complications.
Purpose of the Study:
- To assess the success rate of redo CRT implantation after device extraction due to infection.
- To identify complications, including thrombosis and re-infection, associated with redo CRT procedures.
- To evaluate the long-term prognosis of patients undergoing redo CRT implantation.
Main Methods:
- Retrospective analysis of 125 patients who underwent CRT device and lead extraction between 2007 and 2014.
- Follow-up of 62 patients who underwent redo CRT implantation.
- Analysis of complications, re-infection rates, and survival data.
Main Results:
- Successful re-implantation was achieved in 85% of patients.
- The original coronary sinus (CS) vein could only be reused in 45% of cases.
- One-year all-cause mortality was 7.1%, with higher rates in patients with elevated NT-proBNP, older age, CAD, CKD, AF, or S. aureus infection.
Conclusions:
- Redo CRT implantation after infection extraction has a lower success rate and higher re-infection risk compared to initial implantation.
- Staphylococcus aureus bacteremia is associated with a particularly poor prognosis in patients requiring redo CRT.
Aims:
An increase in the number of cardiac resynchronization therapy (CRT) device implantations worldwide has led to a consequent increase in the number of infections associated with the device, making extraction of the CRT device inevitable. Redo CRT implantation after treatment and recovery following device extraction is challenging. This study aimed to evaluate the success rate, complications, and long-term prognosis of redo CRT implantation, including the rates of subclavian, cava, and coronary sinus (CS) vein thrombosis as well as re-infection.
Methods And Results:
Between 2007 and 2014, 1712 lead extractions were performed in 537 patients with device-related infection at Heart Center Brandenburg. Of the 537 patients, 125 (23%) underwent CRT device and lead extraction, including extraction of the left ventricular lead from the coronary sinus. Of these 125, 62 (50%) patients underwent redo CRT implantation (mean age, 68 ± 10 years); 34 patients had coronary artery disease (CAD) while 28 had dilated cardiomyopathy (DCM). The mean left ventricular ejection fraction was 27% ± 7%. The mean QRS duration of the left bundle branch block was 158 (range, 147-162) ms, and 25 patients had atrial fibrillation (AF). All these patients were followed up for a median duration of 29.6 (range, 15-43) months. In 53 of the 62 patients (85%), the CRT system was successfully re-implanted; however, the original CS vein could be used again only in 28 (45%) patients. The all-cause mortality rate was 7.1% after 1 year, and it was significantly higher in patients whose N-terminal pro B-type natriuretic peptide level was ≥3,000 pg/mL (P < 0.001), those who were aged ≥64 years (P = 0.028), those who had CAD (P = 0.042) or chronic kidney insufficiency (P = 0.001), those with AF (P = 0.001) and those whose blood cultures were positive for Staphylococcus aureus (P = 0.014).
Conclusion:
Redo CRT implantation after device extraction owing to device-related infection has a low success rate and shows a higher rate of re-infection than that observed in patients who undergo CRT implantation for the first time. Further, patients whose blood cultures are positive for S. aureus show a particularly poor outcome.