Intraoperative Three-dimensional Transesophageal Echocardiography Altering Surgical Strategy in Pacemaker Lead Endocarditis

Cardiac implantable electronic device-associated endocarditis continues to pose significant challenges. Although two-dimensional (2D) transesophageal echocardiography (TEE) is considered the diagnostic gold standard, it can underestimate lesion extent and may be insufficient to guide optimal treatment decisions. A 54-year-old male with a history of multiple pacemaker interventions and a retained lead fragment presented with fever, pneumonia, and large right atrial vegetations. Preoperative 2D TEE detected vegetations but did not identify tricuspid valve septal leaflet perforation or subvalvular involvement. Intraoperative three-dimensional (3D) TEE revealed these critical findings, reinforcing the shift from the initially planned percutaneous AngioVac aspiration, chosen due to financial constraints, to surgical lead removal. The patient subsequently underwent tricuspid valve replacement, complete hardware removal, and epicardial pacing. His postoperative course was uneventful. This case underscores the limitations of 2D TEE in complex valvular assessment and the critical role of 3D TEE in defining anatomy, guiding surgical decisions, and averting failed interventions. If AngioVac had been attempted, it likely would have failed to remove subvalvular and perforating vegetations, risking emboli, and persistent infection. In pacemaker-associated endocarditis with suspected leaflet involvement, 3D TEE is invaluable for surgical planning and intraoperative decision-making.