Successful management of multiple permanent pacemaker complications--infection, 13 year old silent lead perforation and exteriorisation following failed percutaneous extraction, superior vena cava obstruction, tricuspid valve endocarditis, pulmonary embolism and prosthetic tricuspid valve thrombosis

Abstract

A 59 year old man underwent mechanical tricuspid valve replacement and removal of pacemaker generator along with 4 pacemaker leads for pacemaker endocarditis and superior vena cava obstruction after an earlier percutaneous extraction had to be abandoned, 13 years ago, due to cardiac arrest, accompanied by silent, unsuspected right atrial perforation and exteriorisation of lead. Postoperative course was complicated by tricuspid valve thrombosis and secondary pulmonary embolism requiring TPA thrombolysis which was instantly successful. A review of literature of pacemaker endocarditis and tricuspid thrombosis along with the relevant management strategies is presented. We believe this case report is unusual on account of non operative management of right atrial lead perforation following an unsuccessful attempt at percutaneous removal of right sided infected pacemaker leads and the incidental discovery of the perforated lead 13 years later at sternotomy, presentation of pacemaker endocarditis with a massive load of vegetations along the entire pacemaker lead tract in superior vena cava, right atrial endocardium, tricuspid valve and right ventricular endocardium, leading to a functional and structural SVC obstruction, requirement of an unusually large dose of warfarin postoperatively occasioned, in all probability, by antibiotic drug interactions, presentation of tricuspid prosthetic valve thrombosis uniquely as vasovagal syncope and isolated hypoxia and near instantaneous resolution of tricuspid prosthetic valve thrombosis with Alteplase thrombolysis.

Figure 1

Chest X ray (PA) showing 2 atrial and 2 ventricular pacing leads and 1 pulse generator in left infraclavicular pocket, the right sided pulse generator having been removed previously.

Figure 2

Transthoracic echocardiogram showing a large right atrial vegetation.

Figure 3

Transthoracic echocardiogram showing vegetations in relation to the endocardial pacing lead.

Figure 4

Intraoperative photograph showing the tip of a pacemaker lead lying outside the right atrium, surrounded by inflammatory granuloma and densely adherent to the undersurface of the sternum.

Figure 5

Intraoperative photograph showing the extra pericardial location of the lead.

Figure 6

Intraoperative photograph showing the inflammatory granuloma having been dissected to reveal the tip of the pacemaker lead.

Figure 7

Intraoperative photograph showing the tip of the pacemaker lead in greater detail.

Figure 8

Intraoperative photograph showing the right ventricular pacemaker lead surrounded by vegetations.

Figure 9

Doppler echocardiogram showing a prolonged pressure half time of 270 msec suggestive of severe prosthetic tricuspid obstruction.

Figure 10

Contrast CT angiogram of left pulmonary artery showing a "wispy" ill defined embolus in the upper lobar artery.

Figure 11

Contrast CT angiogram showing extensive backfilling of azygous system from superior vena cava.

Figure 12

Contrast CT angiogram showing residual stenosis both at the confluence of the two innominate veins and at the junction of SVC with right atrium.

Figure 13

Post thrombolysis Doppler echocardiogram showing complete resolution of tricuspid prosthetic thrombus as suggested by a normal pressure half time.