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Practice patterns and outcomes of cardiac implantable electronic device removal in patients with non-surgically

Amna Alhakak¹, Lauge Østergaard², Niels Eske Bruun^3,4

¹Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark amna.alhakak.01@regionh.dk.

Heart (British Cardiac Society)

|December 16, 2025

Insights

Removing cardiac implantable electronic devices (CIEDs) in patients with infective endocarditis (IE) significantly reduces readmission, recurrent bacteremia, and mortality. This supports current guidelines, though further trials are needed.

Area of Science:

Cardiology
Infectious Diseases
Medical Device Management

Background:

Current guidelines suggest complete cardiac implantable electronic device (CIED) removal for infective endocarditis (IE) but lack strong evidence.
Recommendations are primarily based on expert opinion with a low level of evidence (C).

Purpose of the Study:

To investigate the impact of CIED removal on patient outcomes in infective endocarditis (IE).
To compare IE readmission, recurrent bacteremia, and mortality rates between patients with and without CIED removal.

Main Methods:

A nationwide Danish registry study (2010-2021) included patients aged ≥18 with first-time IE, a CIED, and no valve surgery.
Outcomes (IE readmission, recurrent bacteremia, all-cause mortality) within 6 months post-discharge were compared between CIED removal and non-removal groups.

Main Results:

CIED removal was associated with significantly lower 6-month IE readmission rates (2.5% vs 7.1%, p<0.001).
Patients who underwent CIED removal also had lower rates of recurrent bacteremia (2.1% vs 5.2%, p=0.005) and all-cause mortality (11.5% vs 20.0%, p<0.001).
Multivariable analysis confirmed CIED removal lowered IE readmission (HR 0.39) and mortality (HR 0.70).

Conclusions:

CIED removal in non-surgically managed IE patients with a CIED is linked to better outcomes, supporting existing guidelines.
Further randomized clinical trials are necessary to definitively establish the optimal treatment strategy.

Read full analysis

Abstract

Background:

Current guidelines recommend complete removal of a cardiac implantable electronic device (CIED) in patients with infective endocarditis (IE), although these recommendations are largely based on expert opinion (level of evidence C). We aimed to examine outcomes stratified by CIED removal status in patients with IE.

Methods:

Using Danish nationwide registries (2010-2021), we identified patients aged ≥18 years with first-time IE, who were alive at discharge, managed without valve surgery and had a CIED. Patients who underwent CIED removal during IE admission were compared with those without removal. The study outcomes were IE readmission, recurrent bacteraemia (including IE with the same microbial aetiology) and all-cause mortality within 6 months after discharge.

Results:

The study population comprised 1040 patients with non-surgically managed IE and a CIED, and among these, 596 (57.3%) underwent CIED removal during admission. Patients who underwent removal were younger and less frail than those without removal. In the removal versus non-removal group, the 6-month cumulative incidences were 2.5% (95% CI 1.4% to 4.1%) vs 7.1% (95% CI 4.9% to 9.9%) for IE readmission (p value <0.001), 2.1% (95% CI 1.1% to 3.5%) vs 5.2% (95% CI 3.4% to 7.6%) for recurrent bacteraemia (p value=0.005) and 11.5% (95% CI 9.1% to 14.3%) vs 20.0% (95% CI 16.4% to 23.9%) for all-cause mortality (p value <0.001). In multivariable Cox regression models, CIED removal was associated with lower 6-month rates of IE readmission (HR 0.39 (95% CI 0.19 to 0.79)) and all-cause mortality (HR 0.70 (95% CI 0.49 to 0.996)), compared with no removal.

Conclusions:

In this nationwide study of patients with non-surgically managed IE and a CIED, CIED removal was associated with significantly lower 6-month rates of IE readmission, recurrent bacteraemia and mortality compared with no removal, supporting current guideline recommendations. However, randomised clinical trials are warranted to determine the most effective treatment strategy.

Keywords:

Defibrillators, Implantable Endocarditis Epidemiology Outcome Assessment, Health Care Pacemaker, Artificial

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