Pacemaker lead rupture in a patient with subacute endocarditis: a case report

Abstract

Background: Cardiac implantable electronic device (CIED)-related infections are associated with severe morbidity and mortality. Few cases have previously documented both lead endocarditis and lead rupture simultaneously.

Case summary: We describe the case of a 73-year-old man with a dual-chamber pacemaker presenting with subacute endocarditis and recurrent cholangitis. A few months prior, the patient was diagnosed with localized colon cancer and Streptococcus sanguinis lead endocarditis based on nuclear imaging. He was given prolonged antibiotic therapy and lead explantation was to be performed after sigmoidectomy. During the following weeks, his condition worsened and he was readmitted for biliary sepsis. A chest X-ray revealed, incidentally, a complete ventricular lead rupture. Pacemaker electrogram showed ventricular undersensing, loss of ventricular capture, and high impedance. As his health declined, removal of the pacemaker was deemed unreasonable and the patient died of biliary sepsis in the next few weeks.

Discussion: We describe the case of an asymptomatic intracardiac lead fracture in the setting of colon cancer and a medically managed Streptococcus lead infection. As this complication occurred during lead infection, bacterial damage may have weakened the lead over time. As illustrated by the patient's outcomes, long-term antibiotic therapy should only be used in cases unsuitable for device removal. Complete hardware removal remains the first-line therapy in patients with CIED-related infections.

Keywords: Case report; Fracture; Pacemaker; Pacemaker lead endocarditis; Rupture; Streptococcus sanguinis.

Figure 1

Transoesophageal echocardiograghy shows a 41 × 33 × 15 mm vegetation (arrow), in the right atrium, entrapping the ventricular pacemaker lead. RA, right atrium.

Figure 2

(A) Resting 12-lead electrocardiogram shows sinus rhythm with normal atrioventricular delay, loss of ventricular capture (arrow), ventricular undersensing (asterisk), and intrinsic ventricular depolarization. (B) Pacemaker electrogram shows atrial and ventricular electrogram with ventricular undersensing, lead noise, and loss of ventricular capture. (C) Pacemaker interrogation reveals a gradual decrease in ventricular pacing impedance in May 2020 (insulation breach) followed by a sudden increase in September 2020 (lead fracture). A, atrial lead; AS-FI, atrial sense in refractory period; ATR—Du ↑/↓, atrial tachycardia sense—duration started. ↑ count up/↓ count down; PAC, premature atrial contraction; PVP, postventricular atrial refractory period after a premature ventricular contraction; V, ventricular lead; VP, ventricular pace.

Figure 3

Chest X-ray locating the (1) atrial pacing lead, (2) proximal part of the ventricular lead, and (3) distal part of the ventricular lead. Dissociation of Parts 2 and 3 establishes lead rupture. Left panel: frontal view. Right panel: lateral view. (1) Atrial pacing lead. (2) Proximal part of the ventricular pacing lead. (3) Distal part of the ventricular pacing lead. ANT, anterior; L, left; R, right; POST, posterior.

Figure 4

Positron emission tomography/computed tomography shows increased ¹⁸fluorodesoxyglucose uptake on the extracardiac (A: box) and intracardiac (B: right atrium; C: right ventricle apex) portions of the pacemaker. These coronal images are compatible with pocket infection and lead endocarditis. L, left; R, right.