The catastrophic journey of a retained temporary epicardial pacemaker wire leading toEnterococcus faecalisendocarditis and subsequent stroke

Abstract

SUMMARYA 52-year-old man underwent triple coronary artery bypass graft (CABG). Three months later, he presented to the emergency room with dizziness and left-sided weakness. Workup revealed right frontal parenchymal haemorrhage; also, two retained temporary epicardial pacemaker wires (TEPW) from his previous CABG were observed, one of which had significantly migrated. One wire was found in the soft tissues below the heart; the other transversed the mediastinum from the expected location of the right atrium, perforating the right atrial appendage, entering the lumen of the ascending aorta and coursing into the mid-descending aorta. There were vegetations (Enterococcus spp) on the migrated TEPW and aortic valve, aortic valve endocarditis and aortic regurgitation. In summary, we suspect the migrated TEPW may be the source of bacteria that seeded the aortic valve, causing endocarditis and contributing to the patient's subsequent stroke. Management involved two 6-week antibiotic courses, wire-extraction, aortic valve replacement and redo CABG. BACKGROUND

Rare Intra-Aortic Migration of Temporary Epicardial Pacing Wire

“…Retained TEPWs may act as a nidus for infection and may cause endocarditis or even stroke. 5 6 7 The migration of TEPWs is an unusual but documented complication and poses management challenges. The literature describes the migration of pacing wires to the right heart or main pulmonary artery and less commonly to the left heart or aorta with reports to even distant sites such as jaw, right carotid artery, bronchus, bronchial artery, pleural space, lung parenchyma, peritoneal cavity, transcolonic, and transepidermal migration.…”

Delayed granulomatous reaction and cutaneous fistula induced by retained electrodes from a cardiac pacemaker in a child

“…Surgical extraction of the retained lead required the intervention of cardiac surgeons . Additionally, Dyal highlights a case of infective endocarditis and subsequent stroke secondary to the retained TEPW from a previous coronary bypass in a 52‐year‐old man . The case described by Hsu is dramatic, in which a 49‐year‐old woman presented with impending cardiac tamponade due to the migration of a retained TEPW that led to severe hemopericardium .…”

Characterization of an Enterococcus faecalis Bacteriophage vB_EfaM_LG1 and Its Synergistic Effect With Antibiotic

“…Enterococci are Gram-positive facultative anaerobes, examples of which include E. faecalis and Enterococcus faecium, which cause bacteremia, pneumonia, endocarditis, and urinary tract infections (Beganovic et al, 2018;Jabbari Shiadeh et al, 2019). In addition, E. faecalis is also one of the major pathogens for pneumonia and bacteremia in stroke patients, and the infection after stroke could lead to the death of the stroke patient (Hannawi et al, 2013;Dyal and Sehgal, 2015;Stanley et al, 2016). Moreover, the intrinsic and acquired antibiotic resistance of Enterococci is a formidable public health threat (Arias et al, 2011;Banla et al, 2018).…”