Aortic Endocarditis Caused by Inadvertent Left Ventricular Pacemaker Lead Placement
An 82-year-old man complained of lassitude, sweating, and fever for &5 weeks. On physical examination, a new 3/6 diastolic murmur was heard at the left sternal border, and the patient was admitted with suspected endocarditis. The patient’s history revealed a VVI pacemaker implantation 9 months earlier for unspecified bradycardia at another institution and a transient ischemic attack 2 months before admission. On admission, C-reactive protein was elevated at 68.6 mg/L, and Staphylococcus epidermidis was isolated in several blood cultures. The frontal and lateral views (Figure 1A and 1B) of a chest radiograph showed inadvertent pacemaker lead malpositioning into the left ventricle. Additionally, the right bundle-branch block-like pattern of a paced ECG (Figure 2) gave concern of lead malpositioning. Transthoracic echocardiography confirmed the malpositioning of the pacemaker lead into the left ventricle and demonstrated an aortic valve endocarditis with a moderate to severe aortic regurgitation on color Doppler echocardiography (Figure 3A and 3B). The left ventricular lead position had occurred via an erroneous puncture of the left subclavian artery, which was demonstrated by transesophageal echocardiography with the misplaced lead in the ascending aorta crossing the aortic valve (Figure 4A and 4B). A mechanical irritation of the aortic valve by the misplaced lead could be demonstrated (Figure 4A), which caused endocarditis with a mobile vegetation (&1 cm) and destruction of the right coronary cusp (Figure 4B). The patient was referred to cardiothoracic surgery, and the lead was removed via open sternotomy (Figure 5). The infected valve (Figure 6) was replaced by a 23-mm biological prothesis. Although the pacemaker pocket showed no signs of infection on inspection, the complete pacemaker system was removed. The further clinical course was uneventful, with no bradycardia on repeated Holter ECGs. One of the complications of transvenous pacemaker insertions is the malpositioning of the pacing lead into the left heart. Left ventricular pacing has been reported due to the passage of the pacing lead through the interatrial septum, a patent foramen ovale, a sinus venosus defect, and the interventricular septum, and infrequently, it may arise from erroneous cannulation of the subclavian artery. Reported complications of left ventricular pacing are transient ischemic attacks, cerebral strokes, and vascular complications after cannulation of the subclavian artery, ie, thrombosis. Infective endocarditis of native valves after transvenous pacemaker implantation is rare and mostly affects the tricuspid valve. Left-sided endocarditis was reported secondary to pocket infection and tricuspid valve endocarditis and, in one case, with a mitral valve endocarditis due to a pacemaker lead in the left ventricle through a patent foramen ovale. To the best of our knowledge, this is the first reported case of aortic endocarditis caused by inadvertent left ventricular lead placement through erroneous cannulation of the subclavian artery. It also highlights the importance of meticulous care during pacemaker implantation and careful scrutiny with follow-up radiography, echocardiography, and paced ECGs.