ORIGINAL ARTICLE Contribution of PET imaging to mortality risk stratification in candidates to lead extraction for pacemaker or defibrillator infection: a prospective single center study Igor Diemberger 1 & Rachele Bonfiglioli 2 & Cristian Martignani 1 & Maddalena Graziosi 1 & Mauro Biffi 1 & Stefano Lorenzetti 1 & Matteo Ziacchi 1 & Cristina Nanni 2 & Stefano Fanti 2 & Giuseppe Boriani 3 Received: 4 April 2018 /Accepted: 19 August 2018 # Springer-Verlag GmbH Germany, part of Springer Nature 2018 Abstract Purpose 18 F-FDG PET/CT is an emerging technique for diagnosis of cardiac implantable electronic devices infection (CIEDI). Despite the improvements in transvenous lead extraction (TLE), long-term survival in patients with CIEDI is poor. The aim of the present study was to evaluate whether the extension of CIEDI at 18 F-FDG PET/CT can improve prediction of survival after TLE. Methods Prospective, monocentric observational study enrolling consecutive candidates to TLE for a diagnosis of CIEDI. 18 F- FDG PET/CT was performed in all patients prior TLE. Results There were 105 consecutive patients with confirmed CIEDI enrolled. An increased 18 F-FDG uptake was limited to cardiac implantable electrical device (CIED) pocket in 56 patients, 40 patients had a systemic involvement. We had nine negative PET in patients undergoing prolonged antimicrobial therapy (22.5 ± 14.0 days vs. 8.6 ± 13.0 days; p = 0.005). Implementation of 18 F-FDG PET/CT in modified Duke Criteria lead to reclassification of 23.8% of the patients. After a mean follow-up of 25.0 ± 9.0 months, 31 patients died (29.5%). Patients with CIED pocket involvement at 18 F-FDG PET/CT presented a better survival independently of presence/absence of systemic involvement (HR 0.493, 95%CI 0.240–0.984; p = 0.048). After integration of 18 F-FDG PET/CT data, absence of overt/hidden pocket involvement in CIEDI and a (glomerular filtration rate) GFR < 60 ml/min were the only independent predictors of mortality at long term. Conclusions Patient with CIEDI and a Cold Closed Pocket (i.e., a CIED pocket without skin erosion/perforation nor increased capitation at 18 F-FDG PET/CT) present worse long-term survival. Patient management can benefit by systematic adoption of pre- TLE 18 F-FDG PET/CT through improved identification of CIED related endocarditis (CIEDIE) and hidden involvement of CIED pocket. Keywords CIED . Survival . 18F-FDG PET . Duke criteria . Endocarditis Introduction The technical progress in cardiovascular implantable electrical devices (CIED) occurred in the last decades, and the expan- sion of indications for implantation led to a significant in- crease in the number and complexity of implanted devices for heart rhythm and heart failure management [ 1 ]. Consequently, CIED complications rapidly increased, in par- ticular CIED infection (CIEDI), an issue characterized by a dramatic prognostic impact [2]. In case of CIEDI, complete hardware removal with transvenous lead extraction (TLE) is mandatory as soon as possible [3]. However, despite the im- provement in TLE safety and efficacy the medium-to-long term outcomes of patients with CIEDI is poor, even after a successful TLE [4]. Several predictors of mortality have been * Igor Diemberger igor.diemberger@unibo.it 1 Institute of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Policlinico S.Orsola-Malpighi, Via Massarenti n. 9, 40138 Bologna, Italy 2 Institute of Nuclear Medicine, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Policlinico S.Orsola-Malpighi, Bologna, Italy 3 Cardiology Division, Department of Diagnostics, Clinical and Public Health Medicine, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy European Journal of Nuclear Medicine and Molecular Imaging https://doi.org/10.1007/s00259-018-4142-9