A successful transvenous extraction of giant pacemaker lead endocarditis

Seventy-seven-year-old woman presented to emergency department for a vasculitic rash involving both lower limbs (Figure 1(A)). She had hypertension, diabetes, a dual-chamber pacemaker implantation in 2004 for sick sinus syndrome and a pancreatic neoplasm surgically treated 7 months before. The patient had been doing well until 2 months prior to admission. Oral corticosteroids and topical fusidic acid were prescribed, without any clinical response. A skin biopsy was advised but the patient refused. One month later, she was readmitted for fever, confusion, worsening renal function, nephrotic proteinuria and high levels of WBC count and CRP. On suspicion of parainfectious glomerulonephritis, serial blood cultures were performed, yielding Enterococcus Faecalis. Transthoracic (Figure 1(B)) and transesophageal echocardiography showed the presence of two masses adhering to the right ventricular (RV) lead, a first giant proximal one and a second smaller one (Figure 1(C–E)). Device interrogation was performed showing DDD pacing mode with a mean RV pacing percentage of 38%. Leads impedance, sensing and capture thresholds were within normal ranges. The patient was treated with high-dose Vancomycin and Gentamicin i.v. and, due to high surgical risk, transvenous lead extraction (TLE) was attempted. The leads were disconnected and fixed by Liberator Locking Stylet (Cook-Medical). Evolution Mechanical Dilator Sheath (Cook-Medical) was advanced over the lead-stylet complex to cut fibrotic adhesions and isolate the leads, which were extracted by gentle traction (Figure 1(F)). The postoperative course was uneventful. The patient continued antibiotic therapy for 6 weeks with progressive clinical improvement and a full recovery of renal function. When the blood cultures became negative and the infection was eradicated, a Micra Leadless Pacemaker (Medtronic) was implanted. No adverse event occurred and no relapse was documented at 6-month follow-up. Intracardiac lead vegetation (ILV) with positive blood cultures meets a major Duke criterion for diagnosis of cardiac implantable device infection, that is a class I indication for complete device removal. Decision regarding percutaneous/open-heart removal of ILV > 2 cm, should be individualised. Using novel techniques and a considerable degree of expertise, TLE may be considered the best therapeutic option, even in presence of large ILV.