Successful management of multiple permanent pacemaker complications--infection, 13 year old silent lead perforation and exteriorisation following failed percutaneous extraction, superior vena cava obstruction, tricuspid valve endocarditis, pulmonary embolism and prosthetic tricuspid valve thrombosis

Tricuspid valve endocarditis in non-drug abusers: A case series from India

Objective

The etiology of tricuspid valve endocarditis (TVE) seems to be different in our country as intravenous (IV) drug abuse is not known to be a major health hazard. The objective of this communication is to study the risk factors, clinical profile, follow-up data of TVE patients and focus on the difficulties in diagnosis and variations encountered.

Methods

A retrospective analysis of data of 10 patients of TVE managed in a tertiary care center during January 1992 to June 2015 was done.

Results

TVE was encountered in a diverse subset of patients with cardiac implantable electronic device (CIED) (group I; 3 patients), immunocompromised state with indwelling central venous catheter (CVC) (group II; 2 patients), congenital heart disease (CHD) (group III; 3 patients) and in apparently healthy individuals (group IV; 2 patients). Blood cultures were negative in half the patients. In group I early surgical extraction of leads, device and vegetation provided excellent results. Prognosis was poor with 100% mortality in immunocompromised patients. Patients in group III did well on medical management. The overall mortality was high (30% in hospital and additional 20% within one year).

Conclusions

TVE is rare and can occur in different clinical scenarios. Indiscriminate use of antibiotics modifies the clinical picture causing delay in diagnosis and referral to speciality care. Echocardiography remains the main modality and should be used serially to facilitate early diagnosis. The prognosis is guarded. Early surgery is recommended in pacemaker lead, fungal endocarditis, persistent sepsis or hemodynamic instability for favorable prognosis.

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

BACKGROUND 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.

Late asymptomatic atrial lead perforation, a fortuitous finding during lead extraction using thoracoscopic surveillance: a case report and review of the literature

A 61-year-old male patient was referred for lead extraction of an infected two-chamber pacemaker system first implanted 18 years ago. A new atrial lead was implanted 9 years later because of loss of capture of the original lead. Video-assisted thoracoscopic surgery (VATS) that we use in high-risk cases showed extensive fibrous adhesion between the right atrium wall and the right lung. Dissection of the adhesion revealed the presence of an atrial lead perforated into the lung. After cutting off the lead tip, the residual lead was removed endovascularly from the subclavian site. A literature review of 25 reported cases of late atrial lead perforation was added to the findings in our case report.

Right-sided infective endocarditis: recent epidemiologic changes

BACKGROUND

Infective endocarditis (IE) has been increasingly reported, however, little is available regarding recent development of right-sided IE.

METHODS

Right-sided IE was comprehensively analyzed based on recent 5⅓-year literature.

RESULTS

Portal of entry, implanted foreign material, and repaired congenital heart defects were the main predisposing risk factors. Vegetation size on the right-sided valves was much smaller than those beyond the valves. Multiple logistic regression analysis revealed that predisposing risk factors, and vegetation size and locations were independent predictive risks of patients' survival.

CONCLUSIONS

Changes of right-sided IE in the past 5⅓ years included younger patient age, and increased vegetation size, but still prominent Staphylococcus aureus infections. Complication spectrum has changed into more valve insufficiency, more embolic events, reduced abscess formation, and considerably decreased valve perforations. With effective antibiotic regimens, prognoses of the patients seemed to be better than before.

Long-term outcome of complete cardiovascular implantable electronic device removal with cardiopulmonary bypass

Definitive endovascular techniques have been developed for pacemaker lead extraction; however, a few patients require immediate secondary open heart surgery because of incomplete transvenous lead extraction. This study examined the safety, effectiveness, and long-term outcome of the removal of cardiovascular implantable electronic device (CIED) via median sternotomy under cardiopulmonary bypass. The removal of CIED was performed in 6 patients (mean age 57 ± 16 years, 5 males and 1 female), from September 2000 to April 2011. The reasons for removal included eradication of an infection in 5 patients and elimination of pacemaker component allergy in 1. Positive culture results, including methicillin-sensitive Staphylococcus aureus (MSSA, n = 2), methicillin-resistant S. aureus (MRSA, n = 1), coagulase-negative staphylococci (CNS, n = 1), and methicillin-resistant S. epidermidis (MRSE, n = 1) were observed in all 5 infected patients. Mitral annuloplasty (n = 1), mitral valvuloplasty (n = 1), tricuspid annuloplasty (n = 3). Implantation of myocardial pacing leads (n = 5) were performed concomitantly (n = 4), or secondarily (n = 1). All 6 patients were alive in good condition at 72 ± 55 months following CIED removal. New device infection occurred in 1 patient during long-term follow up. Complete surgical removal of pacing systems via median sternotomy with cardiopulmonary bypass is, therefore, considered to be safe and feasible with acceptable long term results.

Case study and review: treatment of tricuspid prosthetic valve thrombosis

Prosthetic valve thrombosis (PVT) is a severe and life-threatening complication of heart valve replacement. Conventional therapy is surgical thrombectomy or valve replacement. Medical thrombolysis is another emerging option. We report the case of a 57 year old woman with a history of Ebstein anomaly who underwent successful treatment of tricuspid prosthetic valve thrombosis with intra-atrial infusion of very low dose recombinant tissue plasminogen activator (tPA). We review the presentation, etiology, diagnosis, and treatment of tricuspid PVT emphasizing a modified medical option as a safe, minimally invasive alternative to surgical intervention or conventional medical therapy for tricuspid valve thrombosis.