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Does Transvenous Lead Extraction Improve Outcomes for Ventricular Assist Device Patients?

2015; Elsevier BV; Volume: 34; Issue: 4 Linguagem: Inglês

10.1016/j.healun.2015.01.614

1557-3117

Igor Gošev, Melanie Maytin, Julius I. Ejiofor, Marzia Leacche, Siobhan McGurk, Roy M. John, Emer Joyce, Gregory S. Couper, Laurence M. Epstein,

Cardiac Structural Anomalies and Repair

Ventricular Assist Device (VAD) therapy is becoming more common, with >2500 implants in the US in 2013. VAD patients frequently have concomitant cardiovascular implantable electronic devices (CIED). Both of these devices increase patient risks of infection. There is no consensus as to the best clinical practice in VAD patients, in the event of a systemic or local CIED infection. Given the tenuous hemodynamic status and potential for complications, it is unclear whether the risks associated with transvenous lead extraction (TLE) are mitigated by removal of the infected device. We retrospectively reviewed all VAD patients between 2005 and 2014 with CIED in place, to identify those with infection. Patients with (N=13) and without (N=40) TLE were compared. Infection was confirmed by microbiology culture. Major outcomes of interest include complications due to TLE, time to transplant, and mortality. There were 13 VAD patients that underwent TLE with 50 extracted leads; mean age was 50.8 ±14.6yrs, and 31% (4) were women. The median time from initial lead placement to TLE was 75 months. The indication for TLE included lead malfunction in 3 patients and bacteremia or CIED-related infection in the remaining 10. There were no reoperations for bleeding, strokes, or operative mortalities post-TLE. During the follow-up period, two patients died and six were transplanted. Mean survival to transplant time was 1.6 ± 1.4 years. Survival outcomes in the 10 patients undergoing TLE for infection were compared to the cohort of 40 VAD patients with lead intact and confirmed infection (non-TLE). Cumulative survival-to-transplant was 89% at 12 and 24 months each for the TLE group, versus 79% at 12 months and 37% at 24 months for the non-TLE group, with a median survival-to-transplant of 24.0 months for TLE patients versus 16.6 months for non-TLE patients (p=0.09). In this series, TLE in VAD patients was performed predominantly for bacteremia and/or CIED related endocarditis. There were no major complications and no operative mortality. When compared to VAD patients with infection and intact leads, there was better survival-to-transplant in the TLE group. VAD patients can be safely managed with TLE. TLE is associated with improved survival-to-transplant.