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Clinical and Financial Outcomes of Hospitalizations for Cardiac Device Infection During the Covid-19 Pandemic in the Us

Nameer Ascandar, Nikhil Chervu, Syed Shahyan Bakhtiyar, Nam Yong Cho, Shineui Kim, Manuel Orellana, Peyman Benharash


Cardiac device infection (CDI) can occur in up to 2.2% of patients after device placement, with mortality rates exceeding 15%. Although device removal is standard management, the COVID-19 pandemic has been associated with resource diversion and decreased patient presentation for cardiovascular disease. We ascertained the association of the COVID-19 pandemic with outcomes and resource utilization after admission for CDI.


With incremental technologic advances and the availability of evidence-based guidelines, the implantation of intra-cardiac devices has seen a substantial rise in recent years [1]. Permanent pacemakers and defibrillators are increasingly implanted in patients for cardiac resynchronization therapy and prevention of sudden death [2]. However, up to 2.2% of patients experience cardiac device infections (CDI) with reported mortality as high as 16.9% [3,4]. Furthermore, such infections are associated with substantial morbidity and resource use.

Materials and method

This was a retrospective study done in 2023 using the 2016–2020 National Inpatient Sample (NIS). Using International Classification of Diseases, Tenth Edition (ICD-10) code T82.7XXA, we identified all adult (≥18 years) admissions with a primary diagnosis of CDI. Maintained by the Agency for Healthcare Research and Quality as part of the Healthcare Cost and Utilization Project (HCUP), the NIS is the largest publicly available all-payer inpatient database providing accurate estimates for approximately 97% of annual US hospitalizations [12]. Patients with missing data for age, sex, race, costs, death status, or procedural day were excluded from the analysis (4.3%; Fig 1). Accounting for sampling differences and clustering, HCUP provides trend and discharge weights to generate national estimates of all inpatient hospitalizations.


Of an estimated 190,160 patients who met inclusion criteria, 27,260 (14.3%) comprised the pandemic cohort. Among the patients in this group, 650 (2.4%) were noted to be COVID-19 positive. Compared to pre-pandemic, the pandemic cohort was older (62.3 ± 15.3 vs 61.8 ± 15.5 years, P = 0.02), less commonly female (38.9 vs 42.2%, P<0.001), and had a higher mean Elixhauser Index (5.5 ± 2.1 vs 5.3 ± 2.1, P<0.001). In addition, pandemic patients had higher rates of congestive heart failure (47.3 vs 38.7%, P<0.001), and peripheral vascular disease (25.4 vs 21.8%, P<0.001).


Given the significant healthcare burden of CDI, examining access to care and clinical outcomes during the COVID-19 pandemic is particularly instructive and relevant. While prior work has characterized clinical outcomes of patients with cardiac device infection, national examination of these outcomes during the COVID-19 pandemic remains lacking [17,18]. In the present study, we found that volume of patients admitted for CDI drastically decreased during the early months of the COVID-19 pandemic and did not return to baseline. Odds of MAE in patients with CDI was similar during the pandemic compared to prior. Further, despite having a lower overall LOS, hospitalization costs were higher during the pandemic. Several of these findings warrant further discussion.


In summary, the pandemic was not associated with increased or decreased adjusted odds of cardiac device removal rates for CDI. Among those who had a device removal during the pandemic, time from admission to procedure was shorter. Despite higher hospitalization costs, the pandemic did not have a significant impact on clinical outcomes in patients that were admitted for CDI.


The authors would like to thank the members of the CORELab as well as the continued support of the David Geffen School of Medicine and the UCLA Department of Surgery.

Citation: Ascandar N, Chervu N, Bakhtiyar SS, Cho NY, Kim S, Orellana M, et al. (2023) Clinical and financial outcomes of hospitalizations for cardiac device infection during the COVID-19 pandemic in the US. PLoS ONE 18(9): e0291774.

Editor: Tomohiko Ai, Juntendo University: Juntendo Daigaku, JAPAN

Received: April 18, 2023; Accepted: September 5, 2023; Published: September 20, 2023

Copyright: © 2023 Ascandar et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The data underlying the results presented in the study are available from the Healthcare Cost and Utilization Project (HCUP), accessible here:

Funding: The authors(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

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