Lead infections may involve vegetations that require a surgical intervention. Dr. Bruce Wilkoff and Dr. Thomas Callahan discuss situations when consultation with a cardiac surgeon is recommended and factors that suggest surgery vs. transvenous lead removal.
Podcast: Episode 3 – Lead Infections and Endocarditis Transcript
Callahan, M.D., Thomas
Welcome to the Lead Connection podcast where we talk about everything related to lead management. I’m Tom Callahan.
Wilkoff, M.D., Bruce
And I am Bruce Wilkoff. We are both from the Cleveland Clinic Lead Management service.
Wilkoff, M.D., Bruce
Tom, what are we going to talk about this morning?
Callahan, M.D., Thomas
Today I am excited to talk about the situations or scenarios or at least one specific scenario where you might not extract – maybe you call in reinforcements. Specifically looking at the infected population, patients that have CIED infection and looking at factors that might influence you to go to CT surgery for extraction rather than a transvenous lead extraction.
So with that topic in mind, I think the obvious one is if there’s really extensive valve involvement, you know, often that’s going to need to have surgery to be repaired. But thinking about other issues, one that leaps to mind is maybe vegetation size. Do you have specific sort of numbers in mind or criteria in mind when you are looking at this infected population with vegetations that you say, OK, this is getting a little bit large and maybe time to think about surgery.
Wilkoff, M.D., Bruce
Oh, I’d like to step back even a little bit earlier in the in the thought process here and the question is why do people do so badly with endocarditis? Why do they have terrible survival rates at one year? The data we have from the Mayo clinic [Dai M, et al. J Am Coll Cardiol EP 2019;5:1071–80] and now from other data more recently from the Duke data (LBCT ACC 2022 Pokorny et al] that did the 100% Medicare in patient sample is that the mortality rate is miserable.
Callahan, M.D., Thomas
Right, it’s terrible.
Wilkoff, M.D., Bruce
And other than the data from Mayo, we have data from the Brigham previously all saying that the mortality rate in these patients even successfully treated is in the range of 25%. So survival, yeah, these are people that got treated and these are people that got the antibiotics, got rid of the infection source. And the question is why did these people do so badly?
Wilkoff, M.D., Bruce
And I think part of the question is that these things happen in patients with many comorbidities. So maybe not much we can do about it.
Maybe they’re underweight. Maybe they have renal disease. Some of them are on dialysis.
These patients are probably not our healthiest patients that we come across. They already have implantable devices and many of these are defibrillators. Many of them have severe LV dysfunction. So just the setting is part of that, but that’s not all the story and just to pull back a little more data from that 100% Medicare inpatient sample from Duke University and looking at infections, just the delay of extraction put us at an additional 7% mortality at the end of the year. So the delay of more than seven days from the diagnosis, understanding that even that delay added 7% to the yearly mortality there. So, the question is then, well, that’s the problem but why did that happen? And I think my personal hypothesis, and that this is not proven, is that we are chronically seeding the lungs of our patients and that should color the way we look at all of all of this. Is there evidence of pulmonary emboli already?
You know how big the vegetations are, or how big are the vegetations that haven’t embolized that are there? And so clots are forming and breaking off or resolving, hopefully resolving, and we have to think about what’s the next step.
So first is why do these patients do so badly? And I think it’s because of ongoing seeding to the lungs and that these chronic pulmonary embolisms is am I mean the surgeons are going in and scooping out from the pulmonary arteries chronic PE’s. But just imagine if those PE’s are also infected, that’s not going to do any good.
Callahan, M.D., Thomas
Right.
Wilkoff, M.D., Bruce
So you asked me about size and I’m going to say that our job is to protect the patient from more pulmonary emboli. Hopefully reducing the strain on the right heart, reducing and of course those bacteria don’t just go to lungs, but those clots sit there and it adds to the comorbidity of those patients.
Having said that, I think it’s not just size, but also the morphology of the vegetations. Are they flopping back and forth? Are they a big ball? Or – how mobile are they?
And of course, as you alluded to before, are there things on the left side of the heart which we’re not going to address at all here. So those are the questions. Technically, I don’t think extraction has a limit and for patients who have no other options, and there are those patients, we’ve done extractions in people with huge, 3-4-5 centimeter vegetations.
Callahan, M.D., Thomas
Right.
Wilkoff, M.D., Bruce
Steve Kutalek some years ago did a study of out of Philadelphia and he said, they could be 3-4-5 centimeters. It could be done. The question is how do the patients do long term? And so I don’t have a particular limit. I think there are other things that that that make me decide whether to go percutaneously or to consider a surgical extraction.
Callahan, M.D., Thomas
You bring up a lot of great points. You know the fact that these infected patients do really poorly and then questions as to why I think your hypothesis about seeding of the lungs is very plausible.
And to your point, you know, what can we do to improve the outcomes? We’re not just looking to remove the leads, but we want to make sure that they survive the larger process. So what can we do to improve those outcomes? And then just thinking about going back to my question about the vegetation size, really there’s a couple of issues there. When you are dealing with these vegetations, one is are you leaving something behind that’s going to continue to be a sort of a seed for infection.
Are you going to cause problems to lungs but also, is there an acute issue, right? I mean, we’ve seen patients with large vegetations and so forth that can really acutely decompensate when these things break loose.
So, I agree. I don’t think that there’s a specific limit although as the vegetation size goes up, I do start to think more and more about CT surgery, especially if I’m worried that that this vegetation could be large enough to basically cause some human dynamic collapse.
Wilkoff, M.D., Bruce
So, this is not a decision for us alone, so you and I are not CT surgeons. A few lucky extractors are CT surgeons and they can make the decision themselves, but this also is an opportunity to work collaboratively with your surgeon, develop that relationship. They are helping you out in other ways in terms of potential rescue and backup and such like that. And quite frankly, the opportunity here is to do what’s best for the patient, but also to feed your surgeon with some cases that they can work with. The last thing you want to do is make them uncomfortable if they’re going to be backing you up on this case and they say, you know, if this person gets into trouble, there’s not much I can do. If after you did this or that, that we can work on it that way. But if I can do it in a stepwise more controlled way, we have the opportunity not only to get rid of the leads. But also we have a way of doing this in a more controlled fashion.
Callahan, M.D., Thomas
Sure, you’re right.
Wilkoff, M.D., Bruce
Developing that relationship is one of the major goals of a lead extraction program, and you should keep that collaborative relationship in mind at all times.
Callahan, M.D., Thomas
I think that’s exactly right there. There’s a lot of talent and you know personnel in the operating room for extraction that if everybody’s on the same page, can be powerful in making sure that the patient gets through safely including CT surgery, CT, anesthesia or whichever anesthesia service you’re using. So I think that’s exactly right. Trying to make sure that everybody’s on the same page and you keep up those good relationships.
Wilkoff, M.D., Bruce
I wonder, Tom, have you ever gone in and seen one of these endocarditis cases, and when the surgeons open up, it has always impressed me that the echo looks terrible. I mean – no doubt about it. But, when you get into the atrium, you see there is much more infection than you thought there was. There’s much more infected scar and stuff like that. It’s pretty ugly in there and I think in some ways we’re dreaming if we think that we’re actually getting rid of the infection somehow by pulling out those leads and taking out some of the scar and vegetation.
Callahan, M.D., Thomas
You know we talk all the time about the things that we get away with, the things that you know are probably happening unknown to us that we get away with. And I think this is one of them where you know we’re pulling out the leads and maybe the vegetations that we can see on echocardiogram. But that probably vastly underestimates what’s really going on and it’s sort of remarkable if you think about it, that doing what we do, the limited ability that we have to pull out this infected material, that the patients still do as well as they do. I know there is a long way to go in terms of outcomes, but they still do as well as they do.
Callahan, M.D., Thomas
How about PFO? You know, thinking about a patient, infected has a vegetation, does PFO factor into your decision-making in terms of moving forward with TLE.
Wilkoff, M.D., Bruce
Well, it is one of the reasons that I like having a transesophageal echo.
And looking at that, I think it’s not just the PFO, but it’s really the shunt obviously and of course if there have been chronic right sided emboli that increases your right sided pressures and increases the chance also of having a paradoxical embolus. Now I’m going to say this. I think we worry about it a little bit more than it is a reality. I have to say that I am not aware of a single case over my over 30 years of doing extraction where we’ve had a paradoxical embolus. Now having said that, we have been careful, a few of the times where we thought there was a significant right to left shunt. Using cerebral protection as possible. We have done that at times. Also used it when leads go through the aorta or you know they go arterial and situations like that.
But paradoxical emboli are – it’s real – but it’s not a very frequent thing. And but if you have big right sided pressures and you have a big right to left shunt, I think that that is a reason to refer to the surgeon. And having said that, I think there are a few patients that we’ve referred surgery specifically for that point and that usually means there’s a big burden that something else that’s going on. It’s not just you have tricuspid insufficiency and high PA pressures. It may be because you have been embolizing to the lungs and it’s not unusual.
Callahan, M.D., Thomas
And then you know there there’s some talk in the literature about using aspiration devices to try to clear some of this vegetation and material in the process or as part of trends, venous lead extraction. What are your thoughts there? Do you see this as something that we should be using more routinely?
Wilkoff, M.D., Bruce
So I’m going to go back first to my point about the pulmonary emboli and chronic seeding of the lungs. Since the mid 90s. I’ve been trying to promote the development of pulmonary protection. We talked about cerebral protection putting up an umbrella, so to speak, in the pulmonary artery to catch the debris. I am certain that there’s all sorts of debris that the lungs clean up for us. So it’s sort of our extraction drop cloth.
The only way I’m going to be really comfortable doing aspiration and I might want to try to try to break up something and catch it and be able to pull it out is if I had that cerebral and that pulmonary protection.
Callahan, M.D., Thomas
Right.
Wilkoff, M.D., Bruce
But we don’t have those tools, and it’s a nontrivial task to create one. I’m still hopeful that before I retire someday that that there will be something like that or some significant progress that direction.
Getting back to your specific question about looking at these aspiration devices.
Wilkoff, M.D., Bruce
The problem with them are several fold. One is you can get out clot like material and some vegetation like material from these leads there’s no doubt but you don’t know how much you’ve left behind and you don’t know how much that you’ve left behind that has gone to the lungs.
And there’s not a single one of these papers that has done an accounting of how complete a job it is. Of course the problem is you don’t know how much there was at the beginning and the clots are dynamic and so they form and they go away and some of them embolize.
This is a problem so there’s no data on changing the outcomes of these patients. So if there was a study of that it would be worth doing; if we had reason to believe that it was really true, we’d have to study to see if we improve the yearly mortality with these tools. And there are many problems with trying to do that kind of study. Designing it would be tough. So I’m a bit cool on the idea of going in and aspirating. Having said that, we have done it a couple of times a few times and it has worked. The problems is that not all of the substance that’s on the leads is clot and compressible. Some of it is very firm. I mean, if it was all the clot is soft, we wouldn’t have a problem with lead extraction at all. Right. But these things, the scar, can be very firm, they can be calcified. Maybe those are not the ones that break off, but they also not the ones that can’t get sucked off and they can be quite firm and fibrous. I mean just think about what we debride from the pocket. This material’s tough, the material that’s on the lead is tough material and so it’s not so easy. One case we did, we actually needed to extract the lead in order to let get it released from the lead so that we can get it into the suction device and of course, the suction device has to be done under full heparinization.
So there is another issue here in the scenario. There does come a time when you’re doing salvage when you’re trying to take care of a patient that really has no other options – that can’t go to heart surgery, that can’t whatever else like that – and you’re palliating at least trying to do your best to give this person some more time and trying to work on that. I’m glad there’s these options, but the outcomes I just don’t know that we’re going to see that the improvement there. I know there are people that that disagree with me and are very enthusiastic about this but I think it needs to be studied and our tools are still immature.
Callahan, M.D., Thomas
I agree. I think there’s a lot of enthusiasm but not a lot of data and it’s hard to know how this is really affecting outcomes. I think it makes sense in some patients where they don’t have a lot of options but it’s hard to advocate for more than that.
Wilkoff, M.D., Bruce
Right.
Callahan, M.D., Thomas
Well, this has been a great conversation.
Wilkoff, M.D., Bruce
I think so. I mean, it’s just the beginning. I mean this is a complex problem.
CIED infections go from pocket infections to these dramatic infections. There are terrible morbidity and mortality, and every patient is an individual that has an individual problem, a single case. And I think thinking hard about each one as an individual is very important, an individualized approach.
Callahan, M.D., Thomas
Totally agree, absolutely.
Well, thanks for joining us with the Leadconnection podcast and we’ll look forward to another conversation soon.
Wilkoff, M.D., Bruce
Thanks Tom.