Ann Thorac Surg 2008;85:2128-2130. doi:10.1016/j.athoracsur.2007.12.008
© 2008 The Society of Thoracic Surgeons
Case Reports
Pulmonary Valve Replacement for Pacing Electrodes Related Bacterial Endocarditis
Vilém Rohn, MD, PhDa,*,
Marek 
lais, MDa,
Tomá
Kotulák, MDb,
Michal Peni
ka, MDc
a Clinic of Cardiovascular Surgery, Charles University Teaching Hospital, Prague, Czech Republic
b Clinic of Anesthesiology and Resuscitation, Charles University Teaching Hospital, Prague, Czech Republic
c Clinic of Cardiology, Charles University Teaching Hospital, Prague, Czech Republic
Accepted for publication December 3, 2007.
* Address correspondence to Dr Rohn, Clinic of Cardiovascular Surgery, Charles University Teaching Hospital, U Nemocnice 2, 128 00 Praha 2, Czech Republic (Email: vilem.rohn{at}vfn.cz).
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Abstract
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Infective endocarditis of pulmonary valve requiring surgery is rare. We report a case of 80-year-old woman with a permanent pacemaker implanted 14 years ago. She had signs of infection resistant to antibiotic therapy, secondary cachexia, and dyspnea. Echocardiography examination revealed an infectious mass on pacing electrodes in the right atrium, right ventricular dysfunction, and pulmonary hypertension. Removal of the infected pacing system was indicated. During the operation, destruction of the pulmonary valve due to bacterial endocarditis was diagnosed. Replacement with a stented porcine valve was performed. The patient was discharged on postoperative day 20. Seven months after the operation, the patient is in a good condition.
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Introduction
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Late infection of the whole pacemaker system is a serious complication and can become life-threatening. The incidence is currently reported at 0.5% to 1.5% [1, 2]. Infective endocarditis of right-sided valves is very rare, comprising less than 5% of all cases of endocarditis [3, 4]. It is increasingly seen as a reflection of the prevalence of drug abuse and long-term intravenous catheters. We describe a case of infective pulmonary valve endocarditis with destruction of leaflets and a valve dysfunction in a patient with pacemaker wire infection. Removal of the electrodes and pulmonary valve replacement with a xenograft was necessary.
An 80-year-old woman was admitted to Charles University Teaching Hospital from another hospital with signs of chronic infection resistant to antibiotic therapy of 2 weeks' duration. A permanent pacemaker in a dual-chamber, double-sensing, double-rate-modulated pacing (DDDR) mode had been implanted in 1993. She had a history of small pulmonary embolism from 8 months earlier and was placed on anticoagulation therapy with warfarin.
She had cachexia, dyspnea of New York Heart Association function class III, and chest pain. Blood cultures repeatedly grew Staphylococcus epidermidis. Antibiotic therapy with vancomycin and amikacin was started.
On admission, examinations with transthoracic and transesophageal echocardiography were performed. Both revealed a large thrombus (30 x 40 mm) on the pacing wires in the right atrium that was prolabing through the tricuspid valve into the right ventricle, right ventricular dysfunction, and pulmonary hypertension with a pulmonary artery pressure of 62 mm Hg. The reason for pulmonary hypertension was unclear but was presumed to be postembolic. Only mild mitral regurgitation (1+) was present.
Urgent operation was indicated. Through a median sternotomy, cardiopulmonary bypass was initiated, the right atrium was opened, and the pacing electrodes with the large thrombus were removed (Fig 1). The tricuspid valve appeared normal, with a nondilated annulus. Because of right ventricular failure and pulmonary hypertension, we suspected a pulmonary embolism. The pulmonary artery was opened above the valve. There were no emboli in the pulmonary artery, but severe endocarditis of the pulmonary valve with destruction of leaflets was revealed, which was causing leaflet incompetence (Fig 2
and Fig 3).
Radical débridement with valve excision was performed, and the valve was replaced with a 27-mm St. Jude Epic xenograft (St. Jude Medical, St. Paul, MN). Permanent epicardial pacing electrodes were implanted on the right atrium and right ventricle.
Histopathology confirmed thrombus on the pacing electrode, and infectious destruction was documented in the specimen from pulmonary valve. Gram staining revealed gram-positive cocci in both valve and thrombus specimens. The bacteriology of the valve, thrombus, and electrodes all were negative, perhaps due to antibiotic therapy.
The patient's postoperative course was complicated by prolonged mechanical ventilation, with a tracheostomy necessary on postoperative day 5 for the patient's weakness. She was weaned from ventilator and decannulated on day 11 and was discharged from hospital on day 20. We continued her antibiotic therapy for 2 months after the operation. Seven months later, the patient is doing well, with no signs of infection.
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Comment
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Pulmonary valve insufficiency due to endocarditis is rare in patients without predisposing factors [5]. It is difficult to recognize due to its rarity and minimal cardiac manifestations. Although massive pulmonary regurgitation is usually tolerated for a long time, it is not always benign [6]. Deterioration in right heart hemodynamics after pulmonary valvotomy for infective endocarditis without replacement of the valve has been reported [7].
Indications for surgical management in right-sided endocarditis include failure to cure the infection with antibiotics alone, persistent fever, and recurrent pulmonary emboli, or uncontrollable right heart failure. As a replacement of pulmonary valve pulmonary allograft, stentless or stented xenografts are commonly used to reconstruct the right ventricular outflow tract [3, 4, 8].
Infectious endocarditis of the pulmonary valve related to pacing wires infection is very uncommon. It is not well documented in the surgical literature. Its incidence is probably higher than diagnosed. It should be suspected whenever infected catheters or electrodes are in the right atrium. As our case demonstrated, the destruction of the pulmonary valve could be overlooked during the echocardiography examination; therefore, careful preoperative echocardiography concentrated on the pulmonary valve should be performed.
Pulmonary valve excision and radical débridement were necessary in our patient. We replaced the valve with stented porcine xenograft in an acute situation where an allograft was not available.
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References
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- Brodman R, Frame R, Andrews C, Furman S. Removal of infected transvenous leads requiring cardiopulmonary bypass or inflow occlusion J Thorac Cardiovasc Surg 1992;103:649-654.[Abstract]
- Aggarwal RK, Connelly DT, Ray SG, Ball J, Charles RG. Early complications of permanent pacemaker implantation: no difference between dual and single chamber systems Br Heart J 1995;73:571-575.[Abstract/Free Full Text]
- Ayyaz AA, Halstead JC, Hosseinpour AR, Ziad AA, Kumar S, Wallwork J. Replacement of a regurgitant pulmonary valve with a stentless bioprosthesis Ann Thorac Surg 2004;78:1467-1468.[Abstract/Free Full Text]
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- Shimazaki Y, Blackstone EH, Kirklin JW. The natural history of isolated congenital pulmonary valve incompetence—surgical implications Thorac Cardiovasc Surg 1984;32:257-259.[Medline]
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