Extraction of cardiac implantable electronic device leads from patients with severely reduced ejection fraction: Never say “Never”

In this issue of Heart Rhythm Journal, Arora et al 1 Arora Y. Llaneras N. Carrillo R. Strategies and outcomes of patients with severely reduced ejection fraction (≤15%) undergoing transvenous lead extraction: a single center experience. Heart Rhythm. 2022; 19: 2002-2008 Abstract Full Text Full Text PDF Scopus (1) Google Scholar describe an impressive series of patients with severely reduced ejection fraction (SREF) of the left ventricle. All these patients met class I or II indication for lead extraction as put forth in the Heart Rhythm Society guidance document. 2 Kusumoto F.M. Schoenfeld M.H. Wilkoff B.L. et al. HRS expert consensus statement on cardiovascular implantable electronic device lead management and extraction. Heart Rhythm. 2017; 14: e503-e551 Abstract Full Text Full Text PDF PubMed Scopus (530) Google Scholar These patients with SREF predominantly had an infection of the device pocket, endocarditis, or recurrent bacteremia. Recently provided data from Duke University 3 Pokorney SD. Low rates of guideline directed care associated with higher mortality in patients with infections of pacemakers and implantable cardioverter defibrillators. Paper presented at: Late Breaking Clinical Trials at ACC 2022; April 2022; Washington, DC. Google Scholar have shown that guideline-directed therapy for these patients is woefully poor (only 1 in 5), resulting in significantly higher morbidity and mortality (49% lower risk of death when extracted within 6 days of diagnosis). There are likely 2 reasons for the poor adherence to the guidelines. The first is the misconception that antibiotic therapy alone can result in a cure for these types of infections. The second is that lead extraction is “high risk” and quite dangerous. The data from the Duke study clearly show that removal of all foreign material from the device pocket and within the circulation is critical and that antibiotic therapy alone and delay to definitive treatment result in recurrence and death. Data from this study as well as other published registries and databases clearly show that major adverse events are low (1.6% in the data set presented by Arora et al), with a procedurally related death rate ∼0.3% in a multicenter study. 4 Wazni O. Epstein L.M. Carrillo R.G. et al. Lead extraction in the contemporary setting: the LExICon study: a multicenter observational retrospective study of consecutive laser lead extractions. J Am Coll Cardiol. 2010; 55: 579-586 Crossref PubMed Scopus (431) Google Scholar My own personal experience over the past 5 years in the post “Bridge balloon era” suggests that the procedural mortality rate can be as low as 0.15%. Mortality stemming from the infection itself remains much higher than that from lead extraction. Overall mortality from infection is lower when extraction is performed in a timely manner. Strategies and outcomes of patients with severely reduced ejection fraction (≤15%) undergoing transvenous lead extraction: A single-center experienceHeart RhythmVol. 19Issue 12PreviewPatients with severely reduced ejection fraction (SREF ≤15%) are deferred from transvenous lead extraction (TLE) owing to fear of intraoperative hemodynamic collapse. When these patients require lead extraction, their management options are limited, and they suffer from high morbidity and mortality. Left ventricular (LV) assist devices provide intraoperative hemodynamic support and facilitate TLE, enabling lifesaving interventions. Full-Text PDF