INFECTIVE ENDOCARDITIS AFTER ARRHYTHMIA DEVICE IMPLANTATION IN CARDIAC SURGERY PATIENTS

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ABSTRACT Background Patients undergoing cardiac surgery face an increased risk of infective endocarditis (IE), a risk that may be further exacerbated by implantation of cardiac implantable electronic devices (CIED). This study aimed to assess the risk of IE after CIED implantation within 30 days of cardiac surgery and identify associated risk factors. Methods All patients in Sweden, with no previous CIED, who underwent first-time cardiac surgery between 2006 and 2020 were included in this nationwide registry-based study. Cox proportional hazards models adjusted for demographic and clinical covariates were used to estimate the association between CIED implantation and the risk of IE. Results Out of 73,367 patients, 2,302 (3.1%) received a CIED within 30 days. Over a median follow-up of 6.5 years (interquartile range, 3.2–10.1 years), 1,556 patients (2.1%) developed IE. CIED implantation was associated with an increased IE risk (adjusted Hazard ratio (aHR) 1.46; 95% confidence interval (CI) 1.20-1.77). Patients with IE had a significantly higher risk of mortality compared to those without IE (aHR 1.80; 95% CI 1.67-1.94; p<0.001). The type of cardiac surgery influenced IE risk, with valvular surgeries showing a higher incidence than coronary artery bypass grafting. Risk factors independently associated with IE included male sex, age at surgery, diabetes mellitus, and peripheral vascular disease. Conclusions CIED implantation within 30 days after cardiac surgery is associated with an increased long-term risk of IE and subsequent mortality. The type of surgery and patient comorbidities influence the risk. CLINICAL PERSPECTIVE What is new? In this large nationwide registry study, cardiac implantable electronic devices (CIEDs) placed within 30 days after cardiac surgery were associated with a substantial and persistent risk of infective endocarditis. The risk of infective endocarditis was influenced by the type of cardiac surgery and patient-specific factors, rather than the timing of device implantation. What are the clinical implications? Among post–cardiac surgery patients at elevated risk for infective endocarditis (e.g., those undergoing valvular procedures) who require a CIED, selecting devices associated with lower infection risk—such as leadless pacemakers or non-transvenous ICDs—may be a preferable strategy when appropriate. The optimal timing of CIED implantation after cardiac surgery remains uncertain. When delaying implantation, the rationale should center on allowing for potential recovery of conduction abnormalities, rather than attempting to mitigate the risk of device-related infection.

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