Fate of Intracardiac Lead Vegetations After Percutaneous Lead Extraction
Permanent pacemaker (PPM) and implantable cardioverter-defibrillator (ICD) devices are increasingly used in today’s clinical practice. An underappreciated complication and treatment dilemma arises when intracardiac leads become infected from a systemic bacterial infection, at times resulting in large lead vegetations. Two patients (ages 42 and 63 years) with previously implanted devices (ICD and PPM, respectively) presented with fevers and constitutional symptoms and were subsequently found to have bloodstream bacterial infections. Echocardiographic examination revealed several large mobile echodensities adherent to the intracardiac leads consistent with either thrombus, vegetations, or infected thrombi (Movies I and IV). Despite courses of appropriate intravenous antibiotics, fevers, bacteremia, and echocardiographic findings persisted. Surgical consultation was obtained but, in both cases, (because of significant comorbid conditions in one and patient refusal for surgery in the other), a percutaneous approach was pursued.
Under transesophageal echocardiographic surveillance, percutaneous extraction of the intracardiac leads was performed. In the first patient, despite lead removal, a large ventricular ICD lead vegetation remained affixed to the right ventricle, likely adhered to the subvalvular tricuspid valve apparatus. In contrast, removal of the atrial lead led to prompt dislodgement (Movie II) and embolization of a large lead vegetation to the right pulmonary artery (Figure and Movie III), where partial right pulmonary arterial obstruction led to a brief episode of hypotension and tachycardia requiring temporary vasopressor support.
In the second patient, a single PPM lead required extraction. On withdrawal of the lead, the large vegetation remained attached but highly mobile in the right heart, connected to either to a tricuspid leaflet or the subvalvular apparatus (Movie V). Both patients survived the periprocedural period and went on to receive long-term suppressive antibiotic therapy, with considerable delays in the reimplantation of new devices. In an era of increasing use of antiarrhythmia devices and biventricular pacing, the appropriate management of infected intracardiac leads, whether medical, surgical, or percutaneous, has not been well defined and remains vastly unexplored.
Movies I through V are available in an online-only Data Supplement at http://www.circulationaha.org.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.