Stroke in patients with cardiovascular implantable electronic device infection undergoing transvenous lead removal

Background: Stroke can be a devastating complication in patients with cardiovascular implantable electronic device (CIED) infection. Paradoxical septic embolism can occur in the presence of device leads and patent foramen ovale (PFO) via embolic dislodgment during transvenous lead removal (TLR). Objective: The purpose of this study was to examine stroke and its associated factors in patients undergoing TLR for CIED infection. Methods: We performed a retrospective analysis of all patients undergoing TLR for CIED infection from January 1, 2000, to July 30, 2017, from all 3 tertiary referral centers at the Mayo Clinic (Rochester, Phoenix, and Jacksonville). The primary outcome was stroke and was further categorized into preprocedural and postprocedural stroke. Associated risk factors were analyzed. Results: A total of 774 patients (mean age 67.6 ± 14.9 years) underwent TLR for CIED infection. The stroke rate in this cohort was 1.9% (95% confidence interval [CI] 1.1%–3.2%). The preprocedural and postprocedural stroke rate was 0.9% (95% CI 0.4%–1.9%) and 1.0% (95% CI 0.4%–2.0%), respectively. PFOs were identified in 46.7% of patients with stroke and in 12.9% of patients without stroke, and were independently associated with stroke (P =.0002). This was especially in patients with right-sided vegetations with right-to-left shunting (odds ratio 6.4; 95% CI 1.3–31.0; P =.022). Conclusion: In patients with CIED infection undergoing TLR, the presence of PFO, especially with right-sided vegetation with right-to-left shunting, was associated with an increased risk of stroke. This finding suggests that PFO screening before TLR warrants meticulous attention.