Transvenous pacemaker lead removal in pacemaker lead endocarditis with large vegetations: a report of two cases

Abstract

Pacemaker lead endocarditis is treated with total removal of the infected device and proper antibiotics. The outcomes of patients undergoing percutaneous lead extraction for large vegetations (>2 cm) have not yet been shown. In this case report, we present two patients with pacemaker lead endocarditis with large vegetations of maximum diameter 2.4 cm and 3.2 cm. The first patient had multiple vegetations attached to the tricuspid and mitral valves and developed septic emboli to the brain, lung, and liver. The second patient had a large, persistent vegetation on the tricuspid valve, even two weeks after complete removal of the leads. Both patients were successfully treated with transvenous pacemaker lead removal and antibiotics.

Keywords: Cardiac pacemaker, artificial; Endocarditis.

Fig. 1

TTE demonstrating a 2.4×1.1 cm vegetation attached to the TV posterior leaflet (arrow) and a 0.8×0.8 cm vegetation attached to the RA-free wall (broken arrow) (A). A 0.7×0.5 cm vegetation attached to the MV anterior mitral leaflet (B). Disappearance of vegetations on both TV posterior leaflet and RA-free wall (C). Disappearance of MV anterior leaflet vegetation (D). Chest radiograph before device removal (E) and after device removal (F). TTE: transthoracic echocardiography, LA: left atrium, LV: left ventricle, RA: right atrium, TV: tricuspid valve, MV: mitral valve.

Fig. 2

A: brain MRI showing multiple acute infarcts in the bilateral cerebral hemispheres, suggestive of embolism. B: a CT scan of the chest showing small and solid cavitary nodules, suggesting septic embolism. C: a CT scan of the abdomen showing small, ill-defined, low-attenuated lesions in segment 6 of the liver, which can be inflammatory lesions but is difficult to characterize with single-phase CT. CT: computed tomography, MRI: magnetic resonance imaging.

Fig. 3

A: TTE on admission demonstrating a 2.5×1.7 cm TV anterior leaflet vegetation (broken arrow) and a shaggy shaped 1.7×0.8 cm mass attached to the right atrium lateral wall (arrow), concerning for vegetation. Chest radiograph, before infected pacemaker removal (B) and after new pacemaker implantation (C). Follow-up TTE five years later showing disappearance of vegetations (D). TTE: transthoracic echocardiography, LA: left atrium, LV: left ventricle, RA: right atrium, TV: tricuspid valve.