Enterococcus faecalis With a Giant ICD-Lead Vegetation: A Bridge Approach

Rationale Device-related infective endocarditis in older adults is easy to miss when symptoms are nonspecific. When the vegetation is very large, the immediate challenge is clearing the infection without triggering embolization. Patient concerns An 86-year-old woman with diabetes, atrial fibrillation, sick sinus syndrome, non-ischemic dilated cardiomyopathy, and moderate–severe mitral regurgitation presented after 3 days of fatigue, tremor, and weakness. Diagnosis She met SIRS criteria; three blood cultures grew Enterococcus faecalis. Transthoracic echo showed a 40 × 20 mm highly mobile mass on the right-atrial ICD lead and an 8 × 7 mm mitral lesion, consistent with device-related infective endocarditis. Interventions After Cardiology-Team discussion, TEE-guided vacuum debulking (AngioVac) was used first to lower embolic burden. Because a residual mass remained, she then underwent laser-assisted transvenous lead extraction for complete system removal, followed by pathogen-directed IV antibiotics. A wearable defibrillator supported her during recovery. Outcomes Bacteremia cleared without periprocedural complications. At 3 months, TEE showed no vegetations; the mitral valve appeared healed with persistent severe MR and moderate TR. Lessons: In frail, high-risk patients with giant right-sided vegetations, a staged, TEE-guided “debulk then extract” strategy can balance safety with definitive source control, aligning with guideline principles while avoiding default open surgery.