INFECTED AICD WITH LARGE INTRACARDIAC VEGETATION BURDEN

Abstract

TOPIC: Cardiothoracic Surgery TYPE: Medical Student/Resident Case Reports INTRODUCTION: Infective endocarditis of intracardiac electronic devices is a serious disease process that can have many routes of infectious sources. Patients that have a history of cardiac disease with an electronic intracardiac device present must have endocarditis ruled out when they present with sepsis with multiple sources of infection. When patients are found to have endocarditis with large vegetations on the portions of the device multiple approaches can be performed. We present a case of a 73-year-old male with an infected AICD with large intracardiac vegetations on the atrial portion of the device. CASE PRESENTATION: A 73-year-old male presented to the hospital with septic shock with mental status changes and was found to have urine and blood cultures positive for enterococcus faecalis. The patient had a past medical history of ischemic cardiomyopathy, COVID-19, MRSA urinary tract infections, myocardial infarction, and congestive heart failure. The patient was found to have bilateral pyelonephritis which was thought to be the source of his positive cultures, he was started on IV antibiotics. He underwent transesophageal echocardiogram which showed multiple large mobile heterogenous echogenic masses seen attached to the RV lead prolapsing in the tricuspid valve suggestive of vegetations, largest vegetations > 2.5 cm in size. The patient was taken to the operating room and underwent open removal of the infected AICD on cardiopulmonary bypass. An atriotomy was performed with direct vision of removal of the v lead, a lead, and coronary sinus lead. The vegetations along with the AICD were removed in their entirety. Multiple vegetations were removed with the largest vegetation measuring 3.5 cm. The patient's surgery went well along with the remaining portion of his hospital stay. DISCUSSION: Enterococcus faecalis endocarditis with vegetation formation on AICD leads occurs in less than 4% of cases of infected implantable cardiac devices. Pyelonephritis is often a complication from embolic sources from the endocarditis or can be the initial source of infection. All sources of infection must be accounted for when patients are found to have vegetations on TEE. Multiple studies have shown that larger vegetations result in higher morbidity and mortality. CONCLUSIONS: When patients are found to have large vegetations greater than 2.5 cm connected to their implantable cardiac electronic devices or valves early surgical removal of the infected device should be considered to reduce morbidity and mortality for the patient. Large vegetations should be removed using an open technique so the risk of the vegetative mass becoming dislodged and causing a main stem pulmonary embolism can be greatly reduced. REFERENCE #1: Guillermo V. Brazilain Journal of Cardiovascular Surgery- Pacemaker endocarditis with lead extraction for large vegetations, Dec 2009 DISCLOSURES: No relevant relationships by Michael Bishop, source=Web Response