Abstract Body (Do not enter title and authors here): Background: Large (>2 cm) vegetations related to cardiac implantable electronic device (CIED) infections carry a high risk of pulmonary embolism during transvenous lead extraction. Open surgery may not be feasible in high-risk patients. Vacuum-assisted aspiration offers a less invasive alternative, but published data is limited to a few case reports with little emphasis on concomitant lead extraction or follow-up outcomes.
Objective: To evaluate the safety, efficacy, and outcomes of vacuum-assisted removal of large CIED-related infective vegetations with concomitant lead extraction in the largest single-center cohort to date.
Methods and Results: This retrospective series included 22 patients (mean age 60 ± 16 years; 11 females) between 2015 and 2025. Mean vegetation size was 2.5 x 1.4 cm. All patients underwent vacuum-assisted debulking under general anesthesia with fluoroscopic and transesophageal echocardiography guidance, utilizing femoral-femoral veno-venous bypass circuit with a large-bore suction cannula for vegetations aspiration. After adequate debulking, the circuit was discontinued, and transvenous lead extraction was performed using locking stylets and extraction sheaths as needed. Temporary pacing was required perioperatively in four pacemaker-dependent patients. Procedural success, defined as complete or >90% mass removal (n=10) or partial 50%:90% (n=11), was achieved in 21 (95%) cases. One patient required a sternotomy due to a coronary sinus tear during extraction in the setting of atypical anatomy. Another developed septic shock following debulking, and a third experienced transient worsening of tricuspid regurgitation. For successful cases, all leads were successfully extracted in the same procedure with no embolic events perioperatively in any patient. Ten patients underwent successful CIED reimplantation within less than 30 days from the procedure. Within the first 12 post-operative months, four patients died, including one from cardiac arrest despite ICD reimplantation.
Conclusion: Vacuum-assisted removal of large CIED-related vegetations with concomitant lead extraction is a safe, effective surgical alternative, showing improved efficiency and fewer complications with operator experience.