Pacing and Clinical Electrophysiology 2016 Feb;39(2):122-7. doi: 10.1111/pace.12773
Clinical Outcomes of Patients with HIV Undergoing Lead Extraction for Infectious and Noninfectious Indications.
- 1University of Miami Miller School of Medicine, Miami, Florida.
- 2Department of Cardiothoracic Surgery, University of Miami Hospital, Miami, Florida.
Background: With the increasing prevalence of human immunodeficiency virus positive (HIV+) patients in the United States, and the association between HIV and cardiovascular morbidity and mortality, the use of cardiac implantable electronic devices (CIEDs) in patients with HIV has become more common. With the increasing incidence of device-related complications, lead extraction is becoming a topic of importance in this population. As the use of implantable devices increases in the HIV+ population, complications are to be expected; therefore, lead extraction in the HIV population must be addressed.
Methods: From January 2004 to May 2013, 1,018 patients requiring lead extraction were referred to a single, high-volume tertiary cardiovascular center. Within this group of patients, 10 were HIV+. We retrospectively reviewed the charts of this cohort and reported clinical variables of interest.
Results: Infection was the most common indication for lead extraction and device removal. Four patients were in advanced heart failure, and the overall average ejection fraction of the sample population was 32.7 ± 16.3%. In addition, the majority of patients had one or more medical comorbidities. Devices removed, in order of frequency, were implantable cardioverter defibrillators, permanent pacemakers, and cardiac resynchronization therapy devices. On average, 35.6 ± 41.6 months elapsed from implantation of the oldest lead to the date of extraction. There were no major or minor complications and all procedures were clinically successful.
Conclusions: Laser lead extraction is both safe and effective in patients with HIV. This study sets a level of clinical precedent regarding the management of CIED infection or malfunction in patients with HIV.
KEYWORDS: cardiac device infection; cardiac implantable electronic device complications; cardiac implantable electronic device removal; laser sheath; transvenous lead extraction
An increasing number of cardiovascular diseases are being treated with cardiovascular implantable electronic devices (CIEDs). This category of tools, which includes pacemakers and implantable defibrillators, continues to demonstrate benefit in more disease settings. Of course, the increase in implantations has brought an increase in removal procedures, which are required when the devices malfunction or become infected. Removal of devices and their stimulating leads, an operation known as “lead extraction,” requires specialized equipment and teams. Over the last decade, the safety of effectiveness of lead extraction has been studied in many patient populations, both broad and focused. One important group that studies have previously overlooked is the HIV+ population. Cardiac devices carry particular importance for the HIV population. The virus increases the risk for many cardiac diseases such as dilated cardiomyopathy, myocardial infarction, isolated left ventricular failure, pericardial disease, atherosclerosis, myocarditis, arrhythmias, and pulmonary hypertension. We evaluated the procedure in this population using a prospective registry of over one thousand consecutive lead extractions at a single cardiovascular center.
All patients in this database were managed according to a strict protocol. Upon entry to the hospital, each patient was given a chest x-ray and a transthoracic echocardiogram. If further imaging was required, a computed tomography (CT) scan was performed. If the patient was suspected to be suffering from a device-related infection, blood cultures, transesophageal echocardiograms, and tissue samples were ordered. All antibiotic therapy was delivered according to published guidelines. In lead extraction procedures, specialized snares and mechanical or laser cutting sheaths are delivered through the veins under x-ray guidance. In most cases, the only incision is about 10cm at the shoulder for gaining venous access.
Overall, there were 11 extractions in 10 HIV+ patients during the study period. It was found that demographics and comorbidities in the HIV+ patients were similar to the general extraction population. As in the general population, the main reason for lead extraction in this group was device infection. All the surgeries performed on the population of interest were clinically successful, meaning all hardware was removed without complications. In this small population, there was a surprisingly high prevalence of otherwise rare bacteria, which may be a subject for further study. Although the examined group was small, this study represents the largest reported cohort of HIV+ patients undergoing lead extraction. It shows that in high volume centers with trained operators, lead extraction is safe and effective in HIV+ patients.