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 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. These patients with SREF predominantly had an infection of the device pocket, endocarditis, or recurrent bacteremia. Recently provided data from Duke University 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. 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.