Impact of timing of device removal on mortality in patients with cardiovascular implantable electronic device infections

Background: Cardiovascular implantable electronic device (CIED) infections are associated with increased mortality. However, detailed analyses of the impact of device removal on mortality have been limited. Objective: This study sought to evaluate the impact of timing device removal on mortality in patients with CIED infections. Methods: We retrospectively reviewed all cases of CIED infections seen at Mayo Clinic Rochester between 1991 and 2008. The impact of device removal on 30-day and 1-year mortality was evaluated using Cox proportional hazards models. Results: Of 416 patients with CIED infection, 23 (5.5%) died by 30 days and 61 (14.6%) died by 1 year. Forty-four (12.0%) developed complications related to device removal, and 3 (0.8%) died. Complete procedural success was achieved in 341 (81.9%) and clinical success in 391 (93.9%) cases. In multivariate analysis, antimicrobial therapy without device removal was associated with a 7-fold increase in 30-day mortality (hazard ratio [HR] 6.97, 95% confidence interval [CI] 1.36 to 35.60). Although device removal complications were associated with increased mortality at 30 days (HR 4.33, 95% CI 1.47 to 12.70) and at 1 year (HR 3.77, 95% CI 1.88 to 7.55), immediate device removal, when compared to delay in device removal in favor of initial conservative therapy with antimicrobials alone, and no device removal, was associated with a 3-fold decrease in 1-year mortality (HR 0.35, 95% CI 0.16 to 0.75). Conclusion: Although device removal resulted in fatal complications in a few patients, the mortality associated with a delay in device removal was significantly higher. Therefore, early and complete device removal was associated with improved outcomes.