Cardiac Resynchronization Therapy Pacemaker Pocket Infection Complicated by Lead-Related Infective Endocarditis with Subsequent Vegetation Formation on a Temporary Pacing Lead: A Fatal Case in a Patient with a Prior Bentall Procedure

Cardiac implantable electronic device infection is a severe complication whose prognosis worsens when it extends to the leads and when patients carry other intracardiac prosthetic material. We report the case of a 62-year-old woman with a mechanical aortic valve and ascending aortic graft (Bentall procedure) for a bicuspid aortic valve, dilated cardiomyopathy with a left ventricular ejection fraction of 25%, and a cardiac resynchronization therapy pacemaker implanted eight months earlier for high degree atrioventricular block. She presented with an afebrile, red, warm and swollen generator pocket that later fistulized to the skin with purulent discharge. The pocket swab grew methicillin-susceptible Staphylococcus aureus (MSSA), while blood cultures remained sterile. Transthoracic echocardiography showed an 8 × 9 mm mobile mass at the tip of the right atrial lead, confirmed by transesophageal echocardiography, without valvular, prosthetic or graft involvement. Because she was pacemaker dependent, the entire system was extracted and a temporary pacing lead with an external generator was inserted on the contralateral side. Polymerase chain reaction on the extracted leads also identified MSSA, confirming lead-related infective endocarditis. Under intravenous vancomycin, echocardiography revealed two new vegetations measuring 10 × 8 mm on the temporary lead. As blood cultures remained negative, antibiotic therapy was prolonged, and the vegetations resolved within 15 days. On day 37, she developed altered consciousness, hemodynamic collapse and cardiac arrest, and died despite resuscitation. This case highlights the vulnerability of pacemaker-dependent patients after extraction and the need for close surveillance of temporary leads and early reimplantation planning.