Rotating Fibrocalcific Cast After Infected Pacemaker Lead Extraction
A 50-year-old man with a history of sick sinus syndrome had a dual-chamber pacemaker implanted 17 years ago. The pulse generator was replaced for battery depletion (end-of-service) about 12 years earlier and again 4 years earlier. He presented with a 4-month history of a skin lesion over the left subclavicular pacemaker pocket that began as a blister and progressed, despite topical and oral antibiotic therapy, to a partial erosion and exposure of a pacemaker lead.
The pulse generator was explanted and the infected pacemaker pocket was debrided. The chronically implanted atrial and ventricular leads were extracted using a combined Excimer laser sheath (Spectranetics Inc, Colorado Springs, Colo) and Femoral Workstation (Cook Inc, Bloomington, Ind) approach. Fluoroscopy at the end of the procedure revealed no remnants of leads or stylets; however, 2-dimensional transesophageal echocardiography showed an echodense mass that was freely floating and rotating in a tumbling fashion inside the right atrium (Figure, A and Movie). A 35-mm Amplatz gooseneck snare (Microvena Corporation, White Bear Lake, Minn) was advanced through the femoral vein and the mass was grasped under transesophageal echocardiographic guidance and removed. Macroscopic examination of the mass revealed a 3.5×0.7×0.1-cm cast of the extracted lead (Figure, B). A histopathological section stained with hematoxylin and eosin showed benign fibrous tissue with prominent vasculature and focal calcifications (Figure, C).
The patient’s subsequent hospital course was uneventful, with no clinical evidence of pulmonary embolism. Cultures from the atrial lead grew Propionibacterium acnes, which was treated with intravenous vancomycin. Five days after extraction, a new dual-chamber pacemaker system was implanted with pulse generator embedded in the opposite subclavicular pocket. The patient was discharged the next day in good clinical condition with a 4-week course of parenteral antibiotic therapy. Three months later, he was in good health without recurrent infection.
Disruption of the fibrotic attachments between the chronically implanted pacemaker leads and the vascular and intracardiac structures is an inherent part of lead extraction. In the present case, intraoperative transesophageal echocardiography was pivotal in the identification and retrieval of the free-floating, tumbling, radiolucent, and fibrocalcific pacemaker lead cast that likely averted a major complication downstream (pulmonary embolism).
The online-only Data Supplement, which contains a movie, is available online with this article at http://circ.ahajournals.org/cgi/content/full/117/ 20/e338/DC1.