International Journal of Cardiology 190 (2015) 47–48

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Letter to the Editor

Right ventricular lead perforation complicating late pacemaker infection Sothinathan Gurunathan a,⁎, Roxy Senior a,b a b

Department of Cardiology, Royal Brompton Hospital, United Kingdom National Heart and Lung Institute, Imperial College, London, United Kingdom

a r t i c l e

i n f o

Article history: Received 12 April 2015 Accepted 14 April 2015 Available online 16 April 2015 Keywords: Echocardiography Pacemaker infection Cardiac perforation

Dear Editor, ICED (implantable cardiac electronic device) infection complicates almost 2% of ICED implantation. The diagnosis of ICED infection is challenging and often delayed, and outcomes are poor with mortality at 1 year approaching 20%. We report the case of Staphylococcus aureus ICED infection with a rare, life threatening complication. A 72 year old gentleman presented to our institution with a three day history of night sweats, appetite loss and fever. He had a past medical history of myocardial infarction, and permanent pacemaker implantation in 2012 for slow atrial fibrillation. On examination he was febrile. There were no murmurs or signs of endocarditis, and no evidence of pacemaker pocket infection. Staphylococcus aureus (SA) was grown on multiple blood cultures and he was commenced on Flucloxacillin and Rifampicin. On transthoracic echocardiography (TTE) and transoesophageal echocardiography (TOE), there was no evidence of endocardial or pacing lead infection. Following antibiotic therapy, his fever and bacteraemia persisted. In view of his unexplained SA bacteremia, we suspected ICED infection and he was listed for pacemaker extraction. Ten days previously all lead parameters were within normal limits, but he subsequently failed to capture on telemetry. On further interrogation, the right ventricular (RV) lead threshold had increased to 6 V at 1 ms, and migration of the pacing lead was suspected, although this was not evident on chest X-ray. Urgent bedside echocardiography demonstrated a new moderate global perfusion with no evidence of cardiac tamponade. The RV lead was clearly seen to pass through the apex of the right ventricle, with the tip seen in the pericardial space (see Fig. 1 and video clips A and B). Following percutaneous lead extraction and pericardiocentesis, the patient made a full recovery

http://dx.doi.org/10.1016/j.ijcard.2015.04.113 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.

and remains asymptomatic at 6 months, with no current indication for pacemaker implantation. The incidence of cardiac device infection is increasing rapidly, as more devices are implanted. Generator pocket infection and ICED infection often coexist, and in over 70% of cases of pocket infection, there are positive cultures of the intravascular lead segments. However, the diagnosis is often challenging since non-specific signs and symptoms of systemic infection may be the only clinical features. Modified Duke's criteria have been proposed to aid diagnosis, the sensitivity of which may be enhanced by including evidence of pocket infection or echocardiographic evidence of lead vegetations as major criteria [1]. In all suspected cases, echocardiography should be performed to look for evidence of lead vegetation, valvular endocarditis, or myocardial abscess. Although TOE is more sensitive than TTE for this purpose, the techniques should be seen as complementary. Recently 18F-fluorodeoxyglucose positron emission tomography/ computed tomography (18F-FDG PET/CT) has been shown to be beneficial in the evaluation of patients with suspected CIED pocket infection, even in the absence of clinical signs [2]. In cases of CIED infection, prompt removal of all hardware is essential to prevent recurrence of the problem, and over half of patients who do not undergo device removal have relapse. Percutaneous lead extraction is successful in over 98% of cases, with a mortality rate of under 1% in experienced, high volume centres [3]. In up to 30% of cases reimplantation is no longer necessary since initially the device may not have been indicated, or the indication no longer exists [4]. Lead perforation is a rare sequela of device infection, and should be suspected with a sudden increase in pacing thresholds. In suspected cases, bedside echocardiography should be the initial test, and a new pericardial effusion should raise suspicion of this complication. In any patient with an ICED and unexplained bacteraemia, ICED infection should be suspected. Lead perforation is a rare complication of ICED infection, and should be suspected where there is a dramatic change in pacing parameters. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2015.04.113.

Conflict of interest The authors report no relationships that could be construed as a conflict of interest.

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S. Gurunathan, R. Senior / International Journal of Cardiology 190 (2015) 47–48

References [1] J.A. Sandoe, G. Barlow, J.B. Chambers, et al., Guidelines for the diagnosis, prevention and management of implantable cardiac electronic device infection. Report of a joint Working Party project on behalf of the British Society for Antimicrobial Chemotherapy (BSAC, host organization), British Heart Rhythm Society (BHRS), British Cardiovascular Society (BCS), British Heart Valve Society (BHVS) and British Society for Echocardiography (BSE), J. Antimicrob. Chemother. 70 (2) (Feb 2015) 325–359. [2] E. Nof, L.M. Epstein, Complications of cardiac implants: handling device infections, Eur. Heart J. 34 (3) (Jan 2013) 229–236. [3] F.Z. Ahmed, et al., Early diagnosis of cardiac implantable electronic device generator pocket infection using 18F-FDG-PET/CT, Eur. Heart J. Cardiovasc. Imaging (Feb 3 2015) (Epub ahead of print). [4] G.T. Khaldoun, et al., Cardiac implantable electronic device infections: presentation, management, and patient outcomes, Heart Rhythm. 7 (8) (Aug 2010) 1043–1047.

Fig. 1. RV lead seen passing through the right ventricle (shown by white arrows) with the tip seen in the pericardial space (RV — right ventricle, LV — left ventricle, PE — pericardial effusion).

Right ventricular lead perforation complicating late pacemaker infection.

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