• infective endocarditis
• lead extraction
• pacemaker leads
• vegetations

BACKGROUND. With expanding indications for cardiac device implantation, the prevalence of device-related infections is increasing. Patients with device infection and intracardiac vegetations represent a high-risk population with multiple comorbidities and significant mortality, regardless of the management strategy.
OBJECTIVES. The purpose of this study was to assess the feasibility, safety and efficacy of a patient-tailored stepwise approach to the treatment of cardiac devices-related infective endocarditis (CDRIE), including antibiotic therapy and complete tranvenous device removal.
METHODS. Sixty-three consecutive patients with an established diagnosis of CDRIE were prospectively enrolled in the study between January 2010 and August 2012. All patients underwent intra-cardiac echocardiogram before transvenous lead removal (TLR) to assess the presence, size and characteristics of lead-related vegetations. The treatment strategy consisted of a minimum period of at least two weeks of pre-operative specific antibiotic and anticoagulant therapy aimed to reduce the vegetation dimension and the infective burden of the intracardiac mass and surrounding tissues. Such treatment, in presence of stable hemodynamics, was continued until a TLR procedure was considered safe enough, without major risks of massive pulmonary embolism. After TLR, patients received prolonged antibiotic therapy and were followed for at least 6 months.
RESULTS. All patients had lead-related vegetations and 29% of them had vegetations > 20 mm in diameter. 92% of patients received antibiotic treatment before TLR, for a duration of 9,8 ± 5,4 weeks. TLR was attempted in all patients and was successful in the removal of all hardware in 97% of patients. Peri-procedural minor complications were observed in 10% of the patients; no major complication was observed. 30-days in-hospital mortality was 3%, due to overwhelming sepsis despite successful complete device removal. At a follow-up time of 19,4 ± 9,7 months, overall mortality was 10% (all deaths apart from in-hospital deaths were unrelated to CDRIE and its management). A composite end-point including peri-procedural complications and follow-up events was used to identify predictors of Outcome Events: the only independent predictor resulted the presence of a defibrillator lead.
CONCLUSIONS. Our experience suggests that treating patients with medical therapy (specific antibiotics and anticoagulants) also before TLR, even for prolonged periods, in a patient-tailored way, is a both feasible, safe and effective strategy to deal with CDRIE, possibly helping in reducing short-to-mid term mortality after device extraction, in patients with intracardiac lead-related vegetations.