Ann Thorac Surg 2001;72:2130-2132
© 2001 The Society of Thoracic Surgeons
Case report
Pacemaker endocarditis: approach for lead extraction in endocarditis with large vegetations
Albert Miralles, MD*a,
Victor Moncada, MDa,
Hermes Chevez, MDa,
Rafael Rodriguez, MDa,
Jordi Granados, MDa,
Eduard Castells, MDa
a Department of Cardiac Surgery, Ciutat Sanitaria i Universitaria de Bellvitge, Hospital Princeps d’Espanya, Barcelona, Spain
Accepted for publication March 20, 2001.
* Address reprint requests to Dr Miralles, Department of Cardiac Surgery, Ciutat Sanitaria i Universitaria de Bellvitge, Hospital Princeps d’Espanya, Feixa Llarga s/n, 08907 L’Hospitalet de Llobregat, Barcelona, Spain
e-mail: amc{at}csub.scs.es
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Abstract
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We present the case of a patient with vegetations on a pacing lead from a pacemaker implanted 13 years previously. A new surgical technique for removal of infected leads was developed to avoid the increased risk of septic pulmonary embolism. The electrode with vegetations was removed without cardiopulmonary bypass using the direct surgical approach described.
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Introduction
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Infection is the most lethal complication after pacemaker implantation. It is reported in 1% to 19% of patients [1, 2]. Complete removal of all hardware, including leads, is mandatory to ensure eradication of infection and to avoid lead endocarditis. We describe a new approach for lead removal that was successfully used in 1 patient with pacemaker lead endocarditis.
A 66-year-old man with the diagnosis of pacemaker lead endocarditis was admitted to our hospital. He had a 13-year-old VVI pacemaker that had been implanted for bradycardia-tachycardia syndrome. Because of repeated episodes of fever, shaking chills, and sweating, the diagnosis of lead endocarditis was made. Blood cultures grew no pathogens. Empirical antibiotic treatment was given for 4 weeks. Transthoracic echocardiography showed an enlarged lead. Transesophageal echocardiography revealed two large vegetations (15 and 13 mm long) attached to the lead in the right atrium (Fig 1). No tricuspid valve vegetations or perforations were seen.
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Fig 1. Transesophageal echocardiogram showing two giant vegetations (15 and 13 mm long) attached to lead in right atrium.
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Once the diagnosis of pacemaker lead endocarditis was made, the patient was accepted for surgical explantation. Because of the evidence of large vegetations on the lead, transcutaneous traction was not attempted. We used a new approach. A median sternotomy was performed, and the right atrial appendage was partially clamped. An incision 30 mm long was made, and a HEMASHIELD woven graft (Meadox Medicals, Inc, Oakland, NJ) 34 mm in diameter was anastomosed in a end-to-end position using a 5-0 Prolene (Ethicon, Somerville, NJ) suture. The graft was cut 90 mm long. After clamp release, no bleeding was observed, and the pacemaker lead was extracted using a hook (Fig 2). After the vegetations and the tip of the lead had been taken out, the electrode was cut. Its remaining intravascular portion was removed by traction from the site of implantation of the generator without difficulty. The graft was removed, and the incision was closed with a 5-0 Prolene running suture. Transesophageal echocardiography was performed after the procedure. A new pacemaker was implanted in the abdominal wall with an epicardial electrode on the right ventricle. The sternotomy was closed routinely. Samples were sent for culture, and blood cultures grew Staphylococcus epidermis.
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Fig 2. A graft 34 mm in diameter was anastomosed to the right atrium. Using a hook, the pacemaker lead with all adherent vegetations was extracted. With sudden and firm traction, the lead was explanted from the myocardial implantation site.
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The postoperative course was uneventful. Fever episodes disappeared after a 7-day course of vancomycin (1 g/12 h) and aztreonam (1 g/8 h). No evidence of pulmonary embolism was detected. The patient was discharged 10 days later. A transesophageal echocardiographic study was performed 1 month later; no remnants of prosthetic material or vegetations were visible. The patient is completely asymptomatic and leads a normal life.
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Comment
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A mortality rate as high as 66% has been reported when infection of a pacemaker system is left completely untreated [3, 4]. If managed correctly, most patients with pocket infection do not have development of lead endocarditis. Partial explantation usually result in recurrent infection despite antibiotic therapy [5]. Thus, there is wide agreement that when any part of the system is infected, all pacemaker hardware should be removed.
The most simple method for pacemaker lead extraction is direct, gentle manual traction. It has the risk of arrhythmias, trecuspid valve tears, and inversion of the right ventricular apex [6, 7]. Intravascular approaches using wire loop snares, hook-tipped wires, basket retrievers, and grasping forceps have been described, but their use commonly results in uncoiling of the lead or disruption and rupture of the system [8]. Recently a new system with a laser sheath [8] has shown a success rate of 94% [9]. Although infected leads can be removed by nonsurgical approaches, the United States Lead Extraction Database reported a fatal and nearly fatal complication rate of 2.5% with a mortality rate of 0.6% [10].
The presence of lead vegetations poses additional difficulties for explantation, as many methods cannot be used because of the potential hazard of pulmonary embolism. The real incidence of lead vegetations in pacemaker endocarditis is unclear because of the lack of routine transthoracic echocardiography. With transthoracic echocardiography, Klug and associates [4] observed vegetations in 30% of patients compared with 94% using transesophageal echocardiography. They managed these patients depending on the length of the vegetations: percutaneous technique when less than 10 mm long and open heart surgical intervention when longer than 10 mm. The first technique was used in 73% of patients in 30% of them, pulmonary embolus was found on scanning after the procedure. Of patients having open heart surgical procedures, only 1 had a fatal pulmonary embolic event.
Many authors consider a surgical approach with sternotomy to be the safest method when leads have vegetations. Despite the potential risks associated with operation, the risk of death from sepsis or pulmonary embolism is higher if the leads are left in place or if other methods are used [11]. When cardiopulmonary bypass needs to be avoided, the electrodes can be removed through a pursestring in the right atrium, but it is very difficult to remove all material successfully without detachment of vegetations or substantial blood loss. Our procedure easily and safely resolves of these concerns. We think this technique is a good alternative for the management of pacemaker lead endocarditis.
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References
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Heimburger T.S., Duma R.J. Infections of prosthetic valves and cardiac pacemakers. Infect Dis Clin North Am 1989;3:221-245.[Medline]
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Frame R., Brodman R.F., Furman S., et al. Surgical removal of infected transvenous pacemaker leads. PACE 1993;16:2343-2348.
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Phibbs B., Marriott H.J.L. Complications of permanent transvenous pacing. N Engl J Med 1985;312:1428-1432.[Medline]
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Klug D., Lacroix D., Savoye C., et al. Systemic infection related to endocarditis on pacemaker leads: clinical presentation and management. Circulation 1997;95:2098-2107.[Abstract/Free Full Text]
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Marrie T.J., Nelligan J., Costerton J. A scanning and transmission electron microscopic study of an infected endocardial pacemaker lead. Circulation 1982;66:1339-1341.[Abstract/Free Full Text]
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Kratz J.M., Leman R., Gillette P.C. Forceps extraction of permanent pacing leads. Ann Thorac Surg 1990;49:676-677.[Abstract/Free Full Text]
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Praeger P., Kay R., Somberg E., et al. Pacemaker removal—another source of infections. PACE 1984;7:763-764.
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Belott P.H. Endocardial lead extraction. Armonk, NY: Futura, 1998:11-12.
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Byrd C.L., Wilkoff B., Love C., et al. Clinical study of the laser sheath: results of the PLEXES trial. PACE 1997;20:1053.
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Smith H.J., Fearnot N.E., Byrd C.L., Wilkoff B.L., Love C.J., Sellers T.D. Five-years experience with intravascular lead extraction. U.S. Lead Extraction Database. PACE 1994;17(11 Pt 2):2016-2020.
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Brodman R.F., Frame R., Andrews C., et al. Removal of infected transvenous leads requiring cardiopulmonary bypass or inflow occlusion. J Thorac Cardiovasc Surg 1992;103:649-654.[Abstract]
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Abstract
Introduction
