Inter-hospital transfer and timing of lead extractions among patients with device-associated infective endocarditis

Abstract Background Cardiac Implantable Electronic Device (CIED)-associated infective endocarditis (IE) is responsible for significant morbidity and mortality. Current guidelines recommend complete system removal among patients with IE, and growing evidence suggests that delayed transvenous lead extraction (TLE) is associated with worse outcomes. Objective To assess the effect of inter-hospital transfer on timing of TLE among patients with CIED admitted for IE, and determine factors associated with delayed TLE among transferred patients. Method Using the United States Nationwide Readmissions Database (NRD), we identified 25,303 admissions between 2016 and 2019 in the for patients with prior CIED, hospitalized with IE, of whom 3,108 underwent TLE. Timing of TLE was determined based on number of days after admission for IE. Patients were stratified into Early TLE (≤7 days) or Delayed TLE (7 days). Admissions involving inter-hospital transfer were identified. Hospitals were categorized into three tertiles based on annual TLE volume. Results Of the 3,108 patients who had TLE, 1,272 had an inter-hospital transfer. Transferred patients were more likely to have delayed TLE (63.9% vs. 48.8%, p.0001). 18% of transfers were to a Low TLE volume center, 40% to a Mid TLE volume center and 42% to a High TLE volume center. Among transfers, rates of TLE delay were 49.6%, 58.6% and 75.0% in Low, Mid and High TLE volume centers, respectively (p=.0004). Adjusted for comorbidities, Hospital TLE Volume was the strongest factor associated with TLE Delay (aOR 1.7234, CI 1.252 – 2.373, p=0.0009) among transferred patients. Mortality and TLE complication rates were similar irrespective of TLE timing, transfer or procedural volume status. Conclusion Inter-hospital transfer is associated with TLE delay among patients admitted for CIED-associated IE. Furthermore, transfer to a hospital with a higher TLE procedural volume is independently associated with TLE delay