CASE REPORT
Pacemaker lead endocarditis A rare diagnosis with a varied presentation
M. Scheffer, E. van der Linden, R. van Mechelen
We present a patient with a pacemaker lead endocarditis who showed no signs of pocket infection but with high fever and signs of infection in the routine laboratory tests. A diagnosis of pacemaker lead endocarditis must be considered in all patients with fever and infection parameters who have a pacemaker inserted, not only in the first weeks after implantation but also late after implantation, as long as no other cause ofinfection has been found. Transthoracal echocardiography alone is not sensitive enough to establish the correct dignosis. Transoesophageal echocardiography (TEE) is mandatory to demonstrate the presence or absence of a vegetation on a pacemaker lead. (Neth Heart J2003;11:169-72.)
Key words: endocarditis, lead infection, pacemaker nsertion of a permanent pacemaker is a routine
Iprocedure in most community hospitals for a wide variety of indications. Clinicians involved with pacemaker implantations must be familiar with all possible complications. Endocarditis related to pacemaker lead infection is a rare but serious complication. The reported incidence in the literature after permanent endocardial pacemaker implantation varies from 0.13% to 7%.1-4 The presentation can be acute within six weeks after implantation or chronic when there is a delay in the occurrence of symptoms until after six weeks, thus complicating recognition of the diagnosis. The vast majority of patients develop systemic as well as local signs ofinfection facilitating diagnosis. However, this M. Scheffer. E. van der Unden. Department of Cardiology, MCRZ location St. Clara Hospital, Rotterdam. R. van MechWen. Department of Cardiology, St. Franciscus Hospital Rotterdam.
Address for correspondence: M. Scheffer. E-mail: [email protected]
Nethrlands Heart Journal, Volume 11, Number 4, April 2003
is not always the case and pacemaker lead endocarditis must therefore be considered in all patients with an unexplained infection and a pacemaker device. We demonstrate a patient with only systemic symptoms three weeks after implantation due to pacemaker lead endocarditis and pacemaker pocket infection. Case report An 88-year-old man was admitted with high fever and cold chills, three weeks after implantation of a DDD pacemaker system because of symptomatic sick sinus syndrome. The pacemaker pocket showed no erythema, or fluctuation, warmth or tenderness and was not painful (figure 1). The stimulation thresholds and impedance measurements of both leads did not differ from the implantation values. Physical examination revealed no abnormalities. No clinical signs of endocarditis were observed. The laboratory results showed a CRP of90 mg/l and an ESR of 40 mm/h. There was a leucocytosis of 16.8 x 109/1, but no left deviation in the white blood cell count. Neither of the leads showed signs of dislocation on the standard chest X-ray. Staphylococcus aureus was grown in several blood cultures, which made endocarditis a likely diagnosis. Transthoracic echocardiography showed neither vegetations on the heart valves, nor on the leads. There was no pericardial effusion and all chambers had a normal aspect. However, the diagnosis endocarditis was confirmed with TEE because a large sleeve-like vegetation of more than 5 cm was seen at the junction of the vena cava superior to the right atrium, attached to one ofthe pacemaker leads (figure 2). Because of the admirable age of the patient and his poor general condition, surgical removal of the pacemaker device was not feasible and a percutaneous removal was performed, despite the length of the vegetation. The pocket was opened and showed inflammation around the pacemaker with purulent debris. So, the infection was not only confined to the leads, the pacemaker pocket was also involved. Both leads could easily be removed with slight traction. The vegetation attached to the tip of the atrial lead was partially pulled out (figure 3). 169
Pacemaker lead endocarditis
Figure 1. The pacemakerpocket three weeks after implantation: no swelling, no erythema and normal scar tissue is shown.
The pacemaker wound was closed leaving local antibiotics in the pocket. The next day the patient developed septic shock, from which he made an uneventful recovery. Pulmonary embolism was ruled out as the cause of the shock by ventilation perfusion scintigraphy, after removal of the pacemaker leads. Repeated TEE still showed part of the vegetation in the roof of the right atrium (figure 4). Further treatment consisted of a four-week course of intravenous antibiotics. The need for renewed pacemaker implantation during these weeks was confirmed by long periods of asystole alternating with episodes of atrial fibrillation with rapid ventricular rates. A new DDD pacemaker device was implanted at the contra-lateral site, but this time an active fixation atrial lead was screwed into the atrial septum to avoid damaging the remnants of the vegetation in the roof of the right atrium. The ventricular lead was positioned in the right ventricular apex. The patient could be discharged three days after implantation and is being followed up in our outpatient clinic. He has been free of complications for one year now and is in good health. There are no pacemaker-related problems and the ECG shows sinus rhythm or atrial pacing during pacemaker check-up visits. Because ofparoxysmal atrial fibrillation, antiarrhythmic drug therapy was continued after hospital discharge.
Discussion Pacemaker lead endocarditis is a rare but serious complication with high morbidity and mortality.5 7 The clinical picture is characterised by continuous bacteraemia originating from an infected focus located on the pacemaker electrode tip, tricuspid valve8 or fibrotic endocardial areas in contact with the electrode tip. Fever and chills with local pain or abnormalities at the pacemaker site are the most common symptoms, but pacemaker lead endocarditis must also be considered 170
Figure 2. TEE shows a large sleeve-like vegetation attached to the pacemaker leads. RA=right atrium, RV=right ventricle, L=pacemaker leads, V=vegetation. in patients with a pacemaker device if there is accompanying pulmonary pathology or other systemic symptoms, such as arthralgia.5'9 The laboratory results show a high ESRand elevated white blood cell counts with an increase in polymorphonuclear cells. Elevated C-reactive protein is almost always present, but this finding is not specific for pacemaker lead endocarditis. The presentation can be either in an acute form within six weeks of implantation or a chronic form, developing more than six weeks after implantation.9 In the acute form, the short time between implantation and the symptoms developing facilitates the diagnosis, but the variety of symptoms can make it difficult. Also the absence of local or systemic signs of infection can be a problem in establishing the right diagnosis. In our patient, the absence of local symptoms meant that there was no suspicion ofpacemaker-related problems until positive blood cultures were derived. Staphylococcus aureus is the most frequently observed bacteria in lead endocarditis (80%) in the acute form.9 In the chronic form, Staphylococcus epidermidis is responsible for the majority of pacemaker lead infections, but all micro-organisms and even Candida infections6,10,18 can cause pacemaker lead endocarditis. Transthoracic echocardiography has a low detection rate of vegetations in the acute and chronic forms of lead endocarditis.9-11 The diagnosis can be established with TEE, which should always be performed in case of lead endocarditis when transthoracic echocardiography fails to demonstrate vegetations. TEE has a high detection yield of more than 96%.69,12,13 Despite the large sleeve-like vegetation found by TEE, no vegetation or other abnormality was detected in our patient with transthoracic echocardiography, which again confirmed the superiority of TEE Bracke et al.'9 concluded in their review on pacemaker system infections that attempts to treat patients conservatively should be limited to patients with low grade infection
Netherlands Heart Journal, Volume
11, Number 4, April 2003
Pacemaker lead endocarditis
At present, TEE is the best diagnostic technique available for providing the correct diagnosis. However, ifTEE does not demonstrate a vegetation of the lead and fever persists in the presence of positive blood cultures despite optimal antimicrobial therapy adapted to the bacteria found, general agreement exists on the total removal of the pacemaker system [Personal communication: F.A. Bracke, July 2002].. Refmrnces 1
2 3 4
Figure 3. Vegetation at the tip of the atrial kad after removal by traetion ofboth kads. Cultures ofthe tip ofthe lead were positivefor Staphylococcus aureus.
5 6
or skin erosions. The high rate of uncontrolled infection and high mortality in patients with a pacemaker device infection confirms the need for immediate removal of the entire pacing system. 15-1719 KIug et al.9 recommend percutaneous or surgical removal during extracorporeal circulation depending on the size of the vegetation, changes in the tricuspid valve and the general condition of the patient. They suggest surgical removal if TEE demonstrated vegetation >10 mm, while with vegetations
Pacemaker lead endocarditis A rare diagnosis with a varied presentation
M. Scheffer, E. van der Linden, R. van Mechelen
We present a patient with a pacemaker lead endocarditis who showed no signs of pocket infection but with high fever and signs of infection in the routine laboratory tests. A diagnosis of pacemaker lead endocarditis must be considered in all patients with fever and infection parameters who have a pacemaker inserted, not only in the first weeks after implantation but also late after implantation, as long as no other cause ofinfection has been found. Transthoracal echocardiography alone is not sensitive enough to establish the correct dignosis. Transoesophageal echocardiography (TEE) is mandatory to demonstrate the presence or absence of a vegetation on a pacemaker lead. (Neth Heart J2003;11:169-72.)
Key words: endocarditis, lead infection, pacemaker nsertion of a permanent pacemaker is a routine
Iprocedure in most community hospitals for a wide variety of indications. Clinicians involved with pacemaker implantations must be familiar with all possible complications. Endocarditis related to pacemaker lead infection is a rare but serious complication. The reported incidence in the literature after permanent endocardial pacemaker implantation varies from 0.13% to 7%.1-4 The presentation can be acute within six weeks after implantation or chronic when there is a delay in the occurrence of symptoms until after six weeks, thus complicating recognition of the diagnosis. The vast majority of patients develop systemic as well as local signs ofinfection facilitating diagnosis. However, this M. Scheffer. E. van der Unden. Department of Cardiology, MCRZ location St. Clara Hospital, Rotterdam. R. van MechWen. Department of Cardiology, St. Franciscus Hospital Rotterdam.
Address for correspondence: M. Scheffer. E-mail: [email protected]
Nethrlands Heart Journal, Volume 11, Number 4, April 2003
is not always the case and pacemaker lead endocarditis must therefore be considered in all patients with an unexplained infection and a pacemaker device. We demonstrate a patient with only systemic symptoms three weeks after implantation due to pacemaker lead endocarditis and pacemaker pocket infection. Case report An 88-year-old man was admitted with high fever and cold chills, three weeks after implantation of a DDD pacemaker system because of symptomatic sick sinus syndrome. The pacemaker pocket showed no erythema, or fluctuation, warmth or tenderness and was not painful (figure 1). The stimulation thresholds and impedance measurements of both leads did not differ from the implantation values. Physical examination revealed no abnormalities. No clinical signs of endocarditis were observed. The laboratory results showed a CRP of90 mg/l and an ESR of 40 mm/h. There was a leucocytosis of 16.8 x 109/1, but no left deviation in the white blood cell count. Neither of the leads showed signs of dislocation on the standard chest X-ray. Staphylococcus aureus was grown in several blood cultures, which made endocarditis a likely diagnosis. Transthoracic echocardiography showed neither vegetations on the heart valves, nor on the leads. There was no pericardial effusion and all chambers had a normal aspect. However, the diagnosis endocarditis was confirmed with TEE because a large sleeve-like vegetation of more than 5 cm was seen at the junction of the vena cava superior to the right atrium, attached to one ofthe pacemaker leads (figure 2). Because of the admirable age of the patient and his poor general condition, surgical removal of the pacemaker device was not feasible and a percutaneous removal was performed, despite the length of the vegetation. The pocket was opened and showed inflammation around the pacemaker with purulent debris. So, the infection was not only confined to the leads, the pacemaker pocket was also involved. Both leads could easily be removed with slight traction. The vegetation attached to the tip of the atrial lead was partially pulled out (figure 3). 169
Pacemaker lead endocarditis
Figure 1. The pacemakerpocket three weeks after implantation: no swelling, no erythema and normal scar tissue is shown.
The pacemaker wound was closed leaving local antibiotics in the pocket. The next day the patient developed septic shock, from which he made an uneventful recovery. Pulmonary embolism was ruled out as the cause of the shock by ventilation perfusion scintigraphy, after removal of the pacemaker leads. Repeated TEE still showed part of the vegetation in the roof of the right atrium (figure 4). Further treatment consisted of a four-week course of intravenous antibiotics. The need for renewed pacemaker implantation during these weeks was confirmed by long periods of asystole alternating with episodes of atrial fibrillation with rapid ventricular rates. A new DDD pacemaker device was implanted at the contra-lateral site, but this time an active fixation atrial lead was screwed into the atrial septum to avoid damaging the remnants of the vegetation in the roof of the right atrium. The ventricular lead was positioned in the right ventricular apex. The patient could be discharged three days after implantation and is being followed up in our outpatient clinic. He has been free of complications for one year now and is in good health. There are no pacemaker-related problems and the ECG shows sinus rhythm or atrial pacing during pacemaker check-up visits. Because ofparoxysmal atrial fibrillation, antiarrhythmic drug therapy was continued after hospital discharge.
Discussion Pacemaker lead endocarditis is a rare but serious complication with high morbidity and mortality.5 7 The clinical picture is characterised by continuous bacteraemia originating from an infected focus located on the pacemaker electrode tip, tricuspid valve8 or fibrotic endocardial areas in contact with the electrode tip. Fever and chills with local pain or abnormalities at the pacemaker site are the most common symptoms, but pacemaker lead endocarditis must also be considered 170
Figure 2. TEE shows a large sleeve-like vegetation attached to the pacemaker leads. RA=right atrium, RV=right ventricle, L=pacemaker leads, V=vegetation. in patients with a pacemaker device if there is accompanying pulmonary pathology or other systemic symptoms, such as arthralgia.5'9 The laboratory results show a high ESRand elevated white blood cell counts with an increase in polymorphonuclear cells. Elevated C-reactive protein is almost always present, but this finding is not specific for pacemaker lead endocarditis. The presentation can be either in an acute form within six weeks of implantation or a chronic form, developing more than six weeks after implantation.9 In the acute form, the short time between implantation and the symptoms developing facilitates the diagnosis, but the variety of symptoms can make it difficult. Also the absence of local or systemic signs of infection can be a problem in establishing the right diagnosis. In our patient, the absence of local symptoms meant that there was no suspicion ofpacemaker-related problems until positive blood cultures were derived. Staphylococcus aureus is the most frequently observed bacteria in lead endocarditis (80%) in the acute form.9 In the chronic form, Staphylococcus epidermidis is responsible for the majority of pacemaker lead infections, but all micro-organisms and even Candida infections6,10,18 can cause pacemaker lead endocarditis. Transthoracic echocardiography has a low detection rate of vegetations in the acute and chronic forms of lead endocarditis.9-11 The diagnosis can be established with TEE, which should always be performed in case of lead endocarditis when transthoracic echocardiography fails to demonstrate vegetations. TEE has a high detection yield of more than 96%.69,12,13 Despite the large sleeve-like vegetation found by TEE, no vegetation or other abnormality was detected in our patient with transthoracic echocardiography, which again confirmed the superiority of TEE Bracke et al.'9 concluded in their review on pacemaker system infections that attempts to treat patients conservatively should be limited to patients with low grade infection
Netherlands Heart Journal, Volume
11, Number 4, April 2003
Pacemaker lead endocarditis
At present, TEE is the best diagnostic technique available for providing the correct diagnosis. However, ifTEE does not demonstrate a vegetation of the lead and fever persists in the presence of positive blood cultures despite optimal antimicrobial therapy adapted to the bacteria found, general agreement exists on the total removal of the pacemaker system [Personal communication: F.A. Bracke, July 2002].. Refmrnces 1
2 3 4
Figure 3. Vegetation at the tip of the atrial kad after removal by traetion ofboth kads. Cultures ofthe tip ofthe lead were positivefor Staphylococcus aureus.
5 6
or skin erosions. The high rate of uncontrolled infection and high mortality in patients with a pacemaker device infection confirms the need for immediate removal of the entire pacing system. 15-1719 KIug et al.9 recommend percutaneous or surgical removal during extracorporeal circulation depending on the size of the vegetation, changes in the tricuspid valve and the general condition of the patient. They suggest surgical removal if TEE demonstrated vegetation >10 mm, while with vegetations
