title: Impact of timing of device removal on mortality in patients with cardiovascular implantable electronic device infections.
abstract: 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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Mayo School of Graduate Medical Education, Mayo Clinic, Rochester, Minnesota 55905, USA. le.katherine@alumni.mayo.edu
authors.forename: Katherine Y
authors.initials: KY
authors.lastname: Le
authors.forename: Muhammad R
authors.initials: MR
authors.lastname: Sohail
authors.forename: Paul A
authors.initials: PA
authors.lastname: Friedman
authors.forename: Daniel Z
authors.initials: DZ
authors.lastname: Uslan
authors.forename: Stephen S
authors.initials: SS
authors.lastname: Cha
authors.forename: David L
authors.initials: DL
authors.lastname: Hayes
authors.forename: Walter R
authors.initials: WR
authors.lastname: Wilson
authors.forename: James M
authors.initials: JM
authors.lastname: Steckelberg
authors.forename: Larry M
authors.initials: LM
authors.lastname: Baddour
mesh_terms: D000368:Aged; D001145:Arrhythmias, Cardiac / Q000628:therapy; D053821:Cardiovascular Infections / Q000401:mortality / Q000601:surgery*; D017147:Defibrillators, Implantable / Q000009:adverse effects*; D020878:Device Removal / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008910:Minnesota / Q000453:epidemiology; D010138:Pacemaker, Artificial / Q000009:adverse effects*; D016459:Prosthesis-Related Infections / Q000401:mortality / Q000601:surgery*; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D016896:Treatment Outcome