A Rare Entity-Percutaneous Lead Extraction in a Very Late Onset Pacemaker Endocarditis: Case Report and Review of Literature

Abstract

The number of infections related to cardiac implantable electronic devices (CIEDs) has increased as the number of devices implanted around the world has grown exponentially in recent years. CIED complications can sometimes be difficult to diagnose and manage, as in the case of lead-related infective endocarditis. We present the case of a 48-year-old male diagnosed with Staphylococcus aureus device-related infective endocarditis, 12 years after the implant of a single chamber pacemaker. A recent history of the patient includes two urinary catheterizations due to obstructive uropathy in the context of a prostatic adenoma, 2 months previously, both without antibiotic prophylaxis; no other possible entry sites were found and no history of other invasive procedures. After initiation of antibiotic therapy according to antibiotic susceptibility testing, we decided to remove the right ventricular passive fixation lead along with the vegetation and pacemaker generator; because of severe lead adhesions in the costoclavicular region, and especially in the right ventricle, we needed mechanical sheaths to remove the abundant fibrous tissue that encompassed the lead. After a difficult, but successful, lead extraction along with a large vegetation and 6 weeks' antibiotic therapy, the clinical and biological evolution was favorable, without reappearance of symptoms. While very late lead endocarditis is a rarity, late lead-related infective endocarditis (more than 12 months elapsed since implant) is not an exception; this is why we find that endocarditis prophylaxis should be reconsidered in certain patient categories, our patient being proof that procedures with neglectable endocarditis risk according to the guidelines can lead to bacterial endocarditis.

Keywords: cardiac device; endocarditis; infection; late lead extraction; late lead-related infective endocarditis; pacemaker lead endocarditis.

Figure 1

Electrocardiogram revealed sinus rhythm, heart rate 75 beats per minute, intermediate QRS axis, normal morphology.

Figure 2

Antero-posterior chest X-ray: passive fixation lead on the topography of the right ventricle.

Figure 3

Transthoracic two-dimensional echocardiography apical four-chamber view: large hypoechogenic hyper-pedunculated mobile mass (19.5/10 mm) at the level of tricuspid valve.

Figure 4

Transesophageal two-dimensional echocardiography: (a) pedunculated mobile mass (blue, double-headed arrow) attached to pacing lead (19/5 mm); (b) posterior leaflet of the tricuspid valve with hypermobility and rupture of chordae (blue arrow).

Figure 5

Antero-posterior fluoroscopic view of the lead extraction: (a) lead in the right ventricle; (b) lead in the right atrium; (c) lead in superior vena cava; (d) fluoroscopic view after lead extraction.

Figure 6

Extracted lead: (a,b) fibrotic capsule that encased the lead along the distal end and distal region of the lead and large pedunculate vegetation attached (approximately 38/6 mm).

Figure 7

Transesophageal two-dimensional echocardiography: tricuspid chordae rupture, no residual vegetation, no pericardial effusion.

Figure 8

Transthoracic echocardiography, modified parasternal long axis–posterior leaflet of the tricuspid valve with chordal rupture, minor tricuspid regurgitation. (a,b) posterior leaflet of the tricuspid valve with chordal rupture; (c) minor tricuspid regurgitation.