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We read with great interest the article by Carrasco et al. regarding the changes in epidemiology and clinical features of cardiac rhythm device-related infective endocarditis (CDRIE) in a long time period. As stated by the authors, this study provides one of the largest case series of CDRIE and its complications so far. However, several issues drawn our attention. First, the authors reported that 92% of the patients with CDRIE did not have generator pocket infection. Local pocket infection is frequently associated with cardiac rhythm device-related infections, and in most of the cases, it is difficult to discriminate between local pocket and systemic infection associated with these devices. In our series with cardiac rhythm device-related infections, only 15% of the cases were presented with CDRIE without generator pocket infection. Another issue is about the management of CDRIE. Even in sole pocket infections, complete hardware removal is recommended by current guidelines. In patients with definite diagnosis of CDRIE, medical therapy alone is associated with higher morbidity and mortality. In this article, 6 patients (24%) had not undergone hardware removal, mostly due to rapid response to antimicrobial therapy within 48 h. However, according to the modified Duke criteria, diagnosis of infective endocarditis (IE) can be rejected with the resolution of IE symptoms within ≤4 days. Therefore, some of these patients treated with only antibiotics might have an alternative diagnosis other than CDRIE. In addition, incidental masses located on cardiac rhythm device leads are frequently encountered during transoesophageal echocardiographic examinations. At last in this paper, most of the patients underwent surgical hardware removal instead of a transvenous modality (76%). Transvenous lead extraction techniques has facilitated the management of patients of CDRIE, even in the presence of large vegetations and strongly recommended by current guidelines instead of surgery. Despite the increasing use of cardiac rhythm devices in this report, only one patient underwent transvenous lead extraction.

Comment on clinical features and changes in epidemiology of infective endocarditis on pacemaker devices over a 27-year period