Pacemaker lead infection: echocardiographic features, management, and outcome

Abstract

Objective: To compare transthoracic and transoesophageal echocardiography (TTE, TOE) in patients with permanent pacemaker lead infection and to evaluate the safety of medical extraction in cases of large vegetations.

Methods: TTE and TOE were performed in 23 patients with definite pacemaker lead infection. Seventeen patients without previous infection served as a TOE reference for non-infected leads.

Results: TTE was positive in seven cases (30%) whereas with TOE three different types of vegetations attached to the leads were visualised in 21 of the 23 cases (91%). Of the 20 patients with vegetations and lead culture, 17 (85%) had bacteriologically active infection. Left sided valvar endocarditis was diagnosed in two patients. In the control group, strands were visualised by TOE in five patients, and vegetations in none. Medical extraction of vegetations >/= 10 mm was performed in 12 patients and was successful in nine (75%) without clinical pulmonary embolism. After 31.2 (19.1) months of follow up (mean (SD)), all patients except one were cured of infection; three died from other causes.

Conclusions: Combined with bacteriological data, vegetations seen on TOE strongly suggest pacemaker lead infection. Normal TTE examinations do not exclude this diagnosis because of its poor sensitivity. Medical extraction of even large vegetations appeared to be safe.

Figure 1

Transoesophageal echocardiography showing a type 1 vegetation close to an intact tricuspid valve. Note the flattening of the atrial lead. L, lead; RA, right atrium; RV, right ventricle; T, tricuspid valve; >> indicates the vegetation.

Figure 2

Transoesophageal echocardiography showing a type 2 vegetation in the right atrium surrounding the atrial lead and adjacent to the tricuspid. L, lead; RA, right atrium; T, tricuspid valve.

Figure 3

Transoesophageal echocardiography showing a type 3 vegetation in the right atrium close to the tricuspid valve but without valvar endocarditis. L, lead; RA, right atrium; RV, right ventricle; T, tricuspid valve; >> indicates the vegetation.