A Rare Experience of Infective Residual Sheath in the Wall of the Innominate Vein after Extraction of Implantable-Defibrillators

Abstract

Background: Cardiac device-related infective endocarditis is an uncommon but potentially fatal complication. Therefore, cardiac devices should be removed as soon as a device-related infection is suspected.

Case report: A 56-year-old male with a history of arrhythmogenic right ventricular dysplasia with implantable cardioverter-defibrillators (ICDs) 7 years earlier and re-implantation of ICDs due to dysfunction 18 months ago presented with erosion of the ICD pocket with Pseudomonas bacteremia. For the past year, only multiple wound debridements were performed. Accordingly, we performed debridement and removal of the generator during this admission; however, bacteremia still persisted. Using transesophageal echocardiography, we detected vegetation on the pacing leads and tricuspid valve in the right atrium. We performed thoracotomy with tricuspid valve repair and pacing wire removal. However, anterior chest pain and refractory bacteremia occurred 3 months later after discharge, and an infectious foreign body in the wall of the innominate vein was detected using chest computer tomography. Thoracotomy was again performed for resection of the innominate vein with the infection source. Postoperative recovery was good, with no systemic infection or bacteremia.

Conclusions: Pacing lead extraction is a common procedure following cardiac rhythm management device-related infection. However, residual foreign body-related bacteremia should be suspected in cases with fever of unknown origin after primary surgery. Preserving the innominate vein with patch repair is a feasible option. However, a postoperative 4-week course of antibiotics is recommended.

Keywords: Fever of unknown origin; Implantable cardioverter-defibrillator; Infectious foreign body; Innominate vein; Open thoracic surgery; Refractory bacteremia.

Figure 1

(A) Chest CT identified a tube structure (about 3.6 cm in length) in the innominate vein; (B) Intravenous ultrasound showed material with an acoustic shadow at the 3 o’clock position; (C) A segment of innominate vein wall adhered with plastic residual sheath; (D) Histopathology show a picture of foreign body reaction with giant cell infiltration (red arrow) and dystrophic calcification (black arrow) of the venous tissue. CT, computed tomography.

Figure 2

(A) Chest x-ray after removal of generator; (B) Chest x-ray after operation of pacing wire removal and tricuspid valve replacement.