PO-702-03 THE GHOSTS OF LEADS PAST: LEAD CASTS AND RECURRENT BACTEREMIA

Abstract

Lead extraction can be complex and has inherent risk. Many acute complications are related to adhesions and fibrosis developing around chronic leads during removal. However, less appreciated chronic complications include those related to consequences of lead cast(s) retained following lead removal, including but not limited to distal embolization. We report a case of a lead cast identified with 3D intra-cardiac echocardiogram (ICE) after pacemaker extraction and its suspected role in persistent bacteremia. NA A 23-year-old male with repaired Tetralogy of Fallot and complete heart block status post dual chamber pacemaker presented with pacing induced cardiomyopathy. He subsequently underwent extraction of atrial and ventricular leads and implant of a left axillary CRT-D system. Unfortunately, he developed MRSA bacteremia necessitating CRT-D extraction, temporary pacing until bacteremia cleared, and subsequent temporizing leadless pacemaker implantation. During the extraction, two large masses were identified by TEE, which were consistent with fibrin casts retained from the previous atrial and coronary sinus pacing leads. Due to the extent of the retained debris and potential risk of future infection, 3D ICE-guided removal with catheter-based aspiration systems was attempted but was unsuccessful with both the Penumbra and Angiovac systems. Of note, the extent of fibrin deposition was better appreciated on intraprocedural 3D ICE compared to cardiac CT or transesophageal echocardiogram (TEE). One cast in particularly stretched from high SVC into the coronary sinus. In follow-up, bacteremia recurred without alternative source and antibiotics were re-initiated with future plan for surgical removal if required. Lead cast formation after extraction is common and generally carries a benign clinical course when casts are small and bacteremia has cleared; however, we present a case demonstrating both the utility of 3D ICE in visualizing fibrin casts and a concerning clinical course associated with large fibrin casts and development of recurrent bacteremia.