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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 4, July/August 2021
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AFRICA
extraction were low, the long-term outcomes were poor, a finding
that particularly reflects the high-risk population group that
frequently has to undergo CIED implantation and extraction.
9
In our study, CIED infection was the main indication for
lead extraction (69.2% of lead extractions, 69.8% of CIED
removals). The incidence of infections as the primary indication
for lead extraction was almost 20% higher than that from high-
income countries. For example, in the European Lead Extraction
ConTRolled Registry (ELECTRa), out of 3 555 patients who
underwent lead extractions at 73 centres from 19 European
countries, infections were the indication for lead extraction in
52.9% of cases.
11
Additionally, in a multicentre study from 13
sites in the USA and Canada that included 1 449 consecutive
patients who underwent laser-assisted lead extraction, infections
were the indication for extraction in 56%.
13
This probably
reflects our current practice of rarely removing redundant or
non-functional leads. As our experience with lead extraction
grows, removal of non-infected leads is likely to contribute more
to the indications for lead extraction.
In this study we present data from a tertiary referral centre
serving both public and private patients in the Western Cape
province of South Africa. The very low number of patients (26
patients referred for lead extraction procedures over 11 years)
referred for extraction raises two points of potential concern:
•
The finding of a relatively low number of patients who under-
went lead extraction suggests a lack of referral as Groote
Schuur Hospital was the only public hospital performing lead
extractions over this period in the Western Cape province.
This is concerning as patients with CIED are probably inap-
propriately managed with antibiotics and not referred for lead
extraction, which is the only treatment for CIED infection.
Non-removal of an infected CIED is associated with a seven-
fold increase in 30-day mortality and a three-fold increase in
one-year mortality.
20
Furthermore, early removal of infected
CIEDs has been associated with reduced in-hospital mortal-
ity.
21
In a study by Viganego and colleagues, patients who had
their infected CIEDs extracted within three days versus later
than three days of hospitalisation had a lower in-hospital
mortality rate irrespective of antibiotic use (
p
= 0.001).
21
The
rates of CIED implantation in South Africa are increas-
ing,
10,18,22
therefore we expect the rates of CIED infections and
extractions or explant to increase in parallel.
•
Maintaining competency and procedural skills can be difficult
in low-volume centres. Lead-extraction procedural outcomes
are reported to be better in high-volume centres.
16,23
In the
ELECTRa study, rates of extraction-related major compli-
cations and death were significantly lower in high-volume
centres (defined as centres performing more than 30 extraction
procedures per year) when compared to low-volume centres
(less than 30 extraction procedures per year).
11
Furthermore,
for maintenance and transfer of skills, knowledge and compe-
tence in lead extraction, guidance documents recommend a
minimum of 20 extraction procedures on an annual basis.
7
Lead extractions should ideally be conducted in a few highly
specialised public and private referral centres in South Africa.
The major limitations of this study are its retrospective nature
and small sample size. Data on baseline cardiac function as
measured by echocardiography were not available and the
duration of symptoms prior to referral for lead extraction and
explant was also not available.
Conclusion
CIED infections were the primary indication for CIED removal
in a tertiary referral centre in South Africa. Despite being a
low-volume centre, we report a high percutaneous transvenous
extraction success rate with low complication rate, results
which are comparable to high-volume centres. The low number
of patients referred for CIED removal probably reflects poor
management of device infection at the primary healthcare level.
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