Septic Pulmonary Embolism Caused by Infected Pacemaker Leads After Replacement of a Cardiac Resynchronization Therapy Device

Abstract

Patient: Male, 70Final Diagnosis: Pacemaker leads endocarditisSymptoms: Bacterial lead endocarditis • congestive heart failure • fever • pacemaker dysfunctionMedication: —Clinical Procedure: Pacemaker box replacement due to end-of-serviceSpecialty: CardiologyObjective:Unusual clinical courseBackground:Cardiac resynchronization therapy (CRT) has been demonstrated to reduce morbidity and mortality in patients with advanced, drug-refractory heart failure. Procedure-related mortality is less than 1% in larger studies. Approximately10% of CRT patients have to undergo surgical revision because of infections, dislocations, or unacceptable electrical behavior manifested as high threshold, unstable sensing, or unwanted phrenic nerve stimulation.Case Report:A 70-year-old man with symptomatic congestive heart failure underwent implantation of a biventricular pacemaker on the left anterior chest wall in 2003 and pulse generator exchange in August 2009. The patient responded well to CRT. At follow-up, the pacing system functioned normally. In September 2009, in the context of a predialysis program, an abdominal computed tomography (CT) scan was performed in another hospital for assessment and evaluation of chronic kidney disease. This procedure was complicated with peripheral thrombophlebitis that was managed appropriately with complete recovery. Eight months later (May 2010), the patient was admitted to our hospital with fever, anemia, and elevated infection parameters. During admission, blood cultures grew Staphylococcus epidermidis. The chest X-ray, lung perfusion scintigraphy, and CT scan depicted pulmonary embolism and infarction. The right ventricular lead threshold was found to be increased to 7 volts with unsuccessful capture. Echocardiography demonstrated vegetations on leads. The entire pacing system was explanted, but the patient expired few days later following percutaneous removal due to multiorgan failure.Conclusions:In heart failure, replacement of the CRT device may be complicated by bacterial endocarditis. As noted from this case report, sudden elevation of the pacing lead threshold should prompt thorough and immediate investigation to unravel its causes, not only the electrical characteristics but also the anatomical features.

Comparison of the Clinico-Microbiological Characteristics of Culture-Positive and Culture-Negative Septic Pulmonary Embolism: A 10-Year Retrospective Study

“…In SPE, non-thrombotic microorganism-containing emboli disseminating from extrapulmonary primary infectious sources obstruct the small pulmonary vasculature, causing sepsis and multiple small lung abscesses [6]. The primary infectious foci include right-sided infective endocarditis [7,8], soft tissue infections, such as necrotising fasciitis [9,10], implantable device-and catheter-related infections [11][12][13], and odontogenic lesions [3,14]. Due to its nonspecific clinical presentations, diagnosis of SPE remains challenging for clinicians despite its high mortality [15].…”