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This document on cardiovascular infection, including infective endocarditis, is the first in the American Society of Nuclear Cardiology Imaging Indications (ASNC I2) series to assess the role of radionuclide imaging in the multimodality context for the evaluation of complex systemic diseases with multi-societal involvement including pertinent disciplines. A rigorous modified Delphi approach was used to determine consensus clinical indications, diagnostic criteria, and an algorithmic approach to diagnosis of cardiovascular infection including infective endocarditis. Cardiovascular infection incidence is increasing and is associated with high morbidity and mortality. Current strategies based on clinical criteria and an initial echocardiographic imaging approach are effective but often insufficient in complicated cardiovascular infection. Radionuclide imaging with 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) and single photon emission computed tomography/CT leukocyte scintigraphy can enhance the evaluation of suspected cardiovascular infection by increasing diagnostic accuracy, identifying extracardiac involvement, and assessing cardiac implanted device pockets, leads, and all portions of ventricular assist devices. This advanced imaging can aid in key medical and surgical considerations. Consensus diagnostic features include focal/multi-focal or diffuse heterogenous intense 18F-FDG uptake on valvular and prosthetic material, perivalvular areas, device pockets and leads, and ventricular assist device hardware persisting on non-attenuation corrected images. There are numerous clinical indications with a larger role in prosthetic valves, and cardiac devices particularly with possible infective endocarditis or in the setting of prior equivocal or non-diagnostic imaging. Illustrative cases incorporating these consensus recommendations provide additional clarification. Future research is necessary to refine application of these advanced imaging tools for surgical planning, to identify treatment response, and more., (© 2024 The American Society of Nuclear Cardiology, The American College of Cardiology, Heart Rhythm Society, and the Infectious Disease Society of America. Published by Elsevier on behalf of the American Society of Nuclear Cardiology, the American College of Cardiology, Heart Rhythm Society, and by Oxford University Press on behalf of the Infectious Disease Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Aims: Chronic pain at the cardiovascular implantable electronic device (CIED) generator or lead insertion site that is not otherwise manageable carries a IIA indication for extraction. However, limited data exist evaluating causes of pain and outcomes of extraction in eliminating pain. A multi-centre retrospective observational study was conducted to evaluate outcomes of patients undergoing device extraction for treatment of chronic device pain., Methods and Results: Twenty-seven out of 2188 lead extraction candidates (1.3%) met the chronic pain IIA indication for extraction [50 ± 16 years; 14 (51%) women]. Onset, severity, triggers, and pain management were measured before and after extraction. Device type, procedure done (with/without reimplantation), and positive tissue cultures were noted. Pain was reported as constant (n = 14; 50%), intermittent (n = 13; 46%), and movement-triggered (n = 14; 50%). Average severity of pain was seven out of 10 (10 being the worst). Post-extraction, 18 (66%) received freedom from pain, including all patients with poorly formed pockets (n = 2) and subclinical infections (n = 2). Of the 18, 11 underwent reimplantation (61%) without recurrent pain. Nine still had pain (44 ± 17 years; seven women) after extraction. Eight of the nine underwent reimplantation, three on the contralateral chest wall and five ipsilaterally. Pain severity decreased (n = 5), increased (n = 1), or was unchanged (n = 3)., Conclusion: Chronic pain at the CIED generator site can present as chronic or movement-triggered pain, and can be due to subclinical infection or a poorly formed device pocket. Extraction relieved constant and intermittent pain in two-thirds of patients. Extraction appears less successful in eliminating pain in women who undergo subsequent reimplantation., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)

Aims: Outcomes among patients who do not receive device reimplantation after cardiovascular implantable electronic device (CIED) extraction have not been well studied. The present study aims to investigate the outcomes of patients without device reimplantation after lead extraction and device removal., Methods and Results: We retrospectively searched for consecutive patients who underwent CIED extraction at Mayo Clinic, Rochester, MN and University of California San Diego Medical Center from 2001 through 2012. Among the patients identified, we compared characteristics of those who did and did not have device reimplantation. The Kaplan-Meier survival was analysed. Among 678 patients, 97 patients had their device extracted without reimplantation during 1-year follow-up ('no-reimplant group'). Median age was younger in the no-reimplant group (60.7 vs. 70.6 years; P < 0.001). The reasons for no reimplantation were as follows: no longer meeting criteria for CIED (48%), inappropriate device indication at initial implantation (23%), patient preference (17%), and unresolved device complications (12%). Three major arrhythmias were reported in the no-reimplant group. Overall survival in the no-reimplant group was significantly lower than in the reimplant group (60 vs. 93%; P < 0.001). Ongoing device-related complications [hazard ratio (HR), 3.91; 95% CI, 1.74-8.81; P = 0.001], infection (HR, 3.06; 95% CI, 1.24-7.52; P = 0.02), and concurrent dialysis (HR, 2.74; 95% CI, 1.12-6.71; P = 0.03) were associated with increased mortality. Of 31 deaths in the no-reimplant group, 1 was secondary to cardiac arrhythmia., Conclusion: Fourteen per cent of patients who had device extraction did not undergo reimplantation mainly because they no longer met CIED indications. The high mortality in these patients is related to device complications and comorbid conditions, whereas mortality associated with arrhythmia is rare., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals.permissions@oup.com.)

Aims: After extraction of an infected cardiac implantable electronic device (CIED) in a pacemaker-dependent patient, a temporary pacemaker wire may be required for long periods during antibiotic treatment. Loss of capture and under sensing are commonly observed over time with temporary pacemaker wires, and patient mobility is restricted. The use of an externalized permanent active-fixation pacemaker lead connected to a permanent pacemaker generator for temporary pacing may be beneficial because of improved lead stability, and greater patient mobility and comfort. The aim of this study was to investigate the efficacy and safety of a temporary permanent pacemaker (TPPM) system in patients undergoing transvenous lead extraction due to CIED infection., Methods and Results: Of 47 patients who underwent lead extraction due to CIED infection over a 2-year period at our centre, 23 were pacemaker dependent and underwent TPPM implantation. A permanent pacemaker lead was implanted in the right ventricle via the internal jugular vein and connected to a TPPM generator, which was secured externally at the base of the neck. The TPPM was used for a mean of 19.4 ± 11.9 days (median 18 days, range 3-45 days), without loss of capture or sensing failure in any patient. Twelve of 23 patients were discharged home or to a nursing facility with the TPPM until completion of antibiotic treatment and re-implantation of a new permanent pacemaker., Conclusion: External TPPMs are safe and effective in patients requiring long-term pacing after infected CIED removal.

Aims: The aim of the present study was to evaluate the relationship between left ventricular (LV) electrical delay, as measured by the QLV interval, and outcomes in a prospectively designed substudy of the SMART-AV Trial., Methods and Results: This was a multicentre study of patients with advanced heart failure undergoing cardiac resynchronization therapy (CRT) defibrillator implantation. In 426 subjects, QLV was measured as the interval from the onset of the QRS from the surface ECG to the first large peak of the LV electrogram. Left ventricular volumes were measured by echocardiography at baseline and after 6 months of CRT by a blinded core laboratory. Quality of life (QOL) was assessed by a standardized questionnaire. When separated by quartiles based on QLV duration, reverse remodelling response rates (>15% reduction in LV end systolic volume) increased progressively from 38.7 to 68.4% and QOL response rate (>10 points reduction) increased from 50 to 72%. Patients in the highest quartile of QLV had a 3.21-fold increase (1.58-6.50, P = 0.001) in their odds of a reverse remodelling response after correcting for QRS duration, bundle branch block type, and clinical characteristics by multivariate logistic regression analysis., Conclusion: Electrical dyssynchrony, as measured by QLV, was strongly and independently associated with reverse remodelling and QOL with CRT. Acute measurements of QLV may be useful to guide LV lead placement.