Mortality From Infective Endocarditis Related to Cardiovascular Implantable Electronic Devices Declining in U.S.
Key findings
- This nationwide analysis of U.S. hospital discharge data examined the outcomes of 27,257 patients hospitalized with infective endocarditis related to a cardiovascular implantable electronic device (CIED-IE) between 2003 and 2017
- Hospitalizations for CIED-IE increased nearly five-fold during the study period, from 568 to 2,845 (P trend<0.001), and the proportion of CIED-IE cases among all patients hospitalized with IE nearly tripled, from 1.7% to 4.8% (P trend<0.001)
- The average in-hospital mortality rate associated with CIED-IE declined from 15% to 9.7% (P trend=0.032) and was lower than for patients with prosthetic valve endocarditis (PVE) or native valve endocarditis (NVE)
- Certain other complications, such as in-hospital central nervous system infection and stroke, were also less common in CIED-IE than in PVE or NVE, but patients with CIED-IE had longer lengths of stay and higher hospitalization costs
Over the past three decades, there has been a disproportionate increase in the incidence of infections related to cardiovascular implantable electronic devices (CIEDs). The most serious of these in terms of morbidity and mortality is infective endocarditis (CIED-IE), which usually requires the device's extraction and prolonged antibiotic therapy.
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Researchers at Massachusetts General Hospital recently completed the first nationwide study of IE that compared patients hospitalized with CIED-IE, prosthetic valve endocarditis (PVE), and native valve endocarditis (NVE). For patients with CIED-IE, the in-hospital mortality rate decreased over time and was significantly lower than for patients with NVE or PVE.
The findings are reported in the Journal of the American Heart Association by Pegah Khaloo, MD, MPH, and Uwajachukwumma A. Uzomah, MD, MPH, research fellows at the Corrigan Minehan Heart Center at Mass General, Leon M. Ptaszek, MD, PhD, cardiac electrophysiologist in the Corrigan Minehan Heart Center, Jeremy N. Ruskin, MD, founder and director emeritus of the Telemachus & Irene Demoulas Family Foundation Center for Cardiac Arrhythmias, and colleagues.
Methods
From the National Inpatient Sample, the researchers identified adults hospitalized with IE between 2003 and 2017:
- 646,325 total
- 585,974 (90%) had NVE
- 27,257 (4%) had CIED-IE
- 26,111 (4%) had PVE
In-hospital Mortality
During the study period, the primary outcome, the average in-hospital mortality rate associated with CIED-IE, declined from 15% to 9.7% (P trend=0.032). The study design precluded conclusions about the reason, but other results showed patient age decreased significantly over time and rates of device extraction increased.
Predictors of Mortality
Significant predictors of in-hospital mortality among patients with CIED-IE were:
- Acute kidney injury—OR, 2.5
- Incident stroke—OR, 2.3
- Age—OR per year, 1.02
- Coagulopathy—OR, 2.1
- Congestive heart failure—OR, 1.7
- Abnormal weight loss—OR, 1.4
- Infection with Staphylococcus aureus—OR, 1.4
- Chronic kidney disease—OR, 1.3
Other Trends
Between 2003 and 2017, there were increases in the following:
- CIED-IE hospitalizations—from 568 to 2,845 (P trend<0.001)
- The proportion of CIED-IE cases among all patients with IE—from 1.7% to 4.8% (P trend<0.001)
- The proportion of patients with an Elixhauser score >3, a measure of the number of comorbidities—from 52% to 91% (P trend<0.001)
There were significant increases over time in certain complications associated with CIED-IE:
- Acute renal failure—from 20% in 2003 to 49% in 2017 (P trend=0.001)
- Central nervous system (CNS) abscess—from 0% to 1.4% (P trend=0.031)
- Pulmonary embolism—from 3.2% to 17% (P trend<0.001)
There were no significant increases in the frequency of stroke, cardiac valve replacement, or CIED extraction.
Comparisons Between Groups
In-hospital mortality
In-hospital mortality was significantly lower for patients with CIED-IE (9.2%) than for those with PVE (12%; P=0.229) or NVE (12%; P<0.001).
Other complications
Compared with patients with NVE and PVE, patients with CIED-IE had:
- The highest incidence of acute renal failure (38%)
- The lowest incidence of stroke (4.5%)
- The lowest incidence of CNS abscess (0.7%)
The incidence of cardiac valve replacement in patients with CIED-IE (9%) was comparable to that in patients with NVE (10%) and lower than that in patients with PVE (18%).
Healthcare utilization
The average hospital stay was significantly longer for CIED-IE patients than the other two groups, probably because of the frequent requirement for CIED extraction and reimplant. The mean cost per hospitalization was 1.3 and 1.5 times greater than for PVE or NVE, respectively. Most CIED-IE patients had to be discharged to another healthcare facility.
A Tip for Physicians
An interaction analysis revealed that age ≥75, Elixhauser score ≥3, and chronic kidney disease were stronger predictors of mortality in CIED-IE and NVE than in PVE. Considering the increase in the incidence of acute renal failure among patients with CIED-IE during the study period, it may be possible to improve outcomes by carefully monitoring and managing renal function in patients with any of those three factors.
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