Large septic pulmonary embolism complicating extraction of an infected transvenous defibrillator lead

Abstract

1 A-53-year-old man with known coronary artery disease and a istory of sustained monomorphic ventricular tachycardia underent placement of a dual-chamber implantable cardioverter-defirillator (ICD) in 2003. He presented to an outside facility with ever. His blood cultures were positive for Staphylococcus epiermidis, and the patient subsequently was transferred to our acility for further treatment. On physical examination he apeared well. He was afebrile, and his left infraclavicular ICD ocket was benign. A transthoracic echocardiogram (Figure 1A) evealed a large mobile vegetation (1.5 cm 1.5 cm) localized to he ICD lead within the right ventricle as it coursed through the ricuspid valve. Mild tricuspid regurgitation was present. A transenous endocardial lead extraction was performed using a comination of locking stylet and electrocautery dissection. All imlanted hardware was extracted without evidence of retained lead ragments. Immediately after the procedure, a transthoracic echoardiogram showed no evidence of vegetation within the heart and o change in valvular regurgitation. After the procedure, the paient developed left-sided pleuritic chest pain associated with feer. Computed tomographic scan of the chest confirmed a large ulmonary embolus (Figure 1B, filling defect) confined to the eft lower lobe pulmonary artery with evidence of pulmonary nfarction and consolidation (arrowhead). Intraoperative cultures f the pocket and lead tips were negative for bacterial growth; the atient had been receiving intravenous (IV) antibiotics for a few ays prior to the procedure. The patient was treated with 6 weeks f IV antibiotics and recovered without sequelae. He subsequently nderwent repeat ICD placement. With the ever-increasing number of cardiac pacemaker and CD placement procedures, physicians are likely to encounter ore patients with infected intravascular device hardware. he risk of pulmonary embolism complicating extraction of acemaker and ICD leads associated with vegetations 1 cm n size has been highlighted in the literature. The original bservation regarding the risk of embolization and larger vegtations was reported by Mugge et al, who demonstrated that 2 (47%) of 47 patients with vegetations 1 cm had evidence