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Giant vegetation on permanent endocavitary pacemaker lead and successful open intracardiac removal/Kalp ici yerlesimli kalici pacemaker teli uzerinde bulgulanan dev vejetasyon ve basarili acik cerrahi yaklasimla cikarilmasi.


Pacemakers (PMs) and implantable cardioverter defibrillators (ICDs) have become life-saving therapeutic tools for patients with cardiac arrhythmia (1). The incidence of infective endocarditis due to pacemaker lead infection ranges between 0.13% and 19.9% (2). The incidence of serious and potentially fatal complications such as endocarditis and septicemia is around 0.5% (3).

Case report

Our case was a 58-year-old male who had undergone a VVI mode PM implantation 15 years ago at the Cardiology Department of our institute due to total atrioventricular block. Two months before his present admission he started to experience chills and shivering as the main complaints. For the last three weeks he also had fever. He had diabetes mellitus. At the time of his admission, a transthoracic echocardiography (TTE) was performed showing a giant vegetation attached on intracardiac pacemaker lead. Transesophageal echocardiography (TEE) also confirmed these vegetative masses of 27x19 and 17x12 mm in size (Fig. 1). His body temperature was measured as 39[degrees]C. Initially, a leucocytosis of 13.4x[10.sup.9]/l was associated with a neutrophilia of 11.1x[10.sup.9]/l. Biochemical abnormalities included elevated creatine kinase of 201 IU/I, erythrocyte sedimentation rate of 75mm/h and Creactive protein of 20.52 mg/l. An empirical antibiotherapy with intravenous cephtriaxone and gentamicin was initiated. Initial blood cultures grew methicillinsensitive Staphylococcus aureus. Antibiotic cover was changed to teicoplanin after sensitivities were obtained, with the addition of gentamicin for synergistic bactericidal effect. After 5 weeks of antibiotherapy and weekly repeated echocardiograms showing no shrinkage of vegetations, surgical therapy consisting of 3 stages was planned. In the first stage, following median sternotomy a pocket for the generator was prepared at the left pectoral area and a new permanent epicardial pacemaker (St Jude Medical Identity ADxSR SSIR 5180,REF:1084T-54CM) was implanted . In the second stage, with the help of inflow occlusion technique right atriotomy was performed and the pacemaker lead was extracted with the attached giant vegetations (Fig. 2,3). In the last stage, the former pacemaker generator localized at the right pectoral area and its transvenous electrode were removed in order to complete explantation. Therapy with antibiotics was continued for 6 more weeks postoperatively. Outpatient follow-up was carried out by Cardiology department and no further problems were recorded.




The overall incidence of confirmed cardiac device infection in a cohort of adult patients with spontaneous 5. aureus bacteraemia and permanent pacemakers or implantable cardioverter defibrillators over a 6-year period was 45.4%, emphasizing the importance of preventing S. aureus bacteraemia in patients with cardiac devices (4).

In general, fever is the most frequent and dominant symptom in pacemaker associated endocarditis. The body temperature is generally subfebrile of long duration. Chills and shivering may accompany this situation. These symptoms are mostly subacute or chronic delaying the proper diagnosis. The period from the onset of fever to the diagnosis of endocarditis may last 3 to 4 months (5). In pacemaker -associated endocarditis, the diagnosis is generally made by modified Duke's criteria. Most valuable laboratory data are positive blood culture and -as in our case- demonstration of vegetation echocardiographically.


Echocardiography permits the direct imaging of valvular vegetations, and it allows for the identification of structural complications of endocarditis. It is useful for characterizing the hemodynamic consequences of the infection. It can also provide prognostic information concerning risk of embolization and/or need for cardiac surgery (6). The superiority of transesophageal echocardiogram (TEE) over transthoracic echocardiogram for detecting vegetations is proven (2,5). In 90 to 95% of cases, it is possible via TEE to demonstrate the vegetations attached on lead system.

Arber and his colleagues (7) from Israel investigated 44 cases with PM endocarditis in terms of coexistence of diabetes mellitus between years 1982 and 1992. In this population diabetes mellitus was seen more commonly compared to general prevalence and is therefore defined as a risk factor (7).

Conservative medical therapy often fails in lead endocarditis developed in less than 1% of patients with PM (8). Extraction/ explantation under antibiotherapy is effective in eradication of infection and has a mortality rate of 12.5%. Therefore, complete extraction should be a part of the standard therapy (2).


Pacemaker lead infections have been associated with high degrees of morbidity and high mortality rates (8). The seriousness of this condition requires early diagnosis and treatment (2). Transesophageal echocardiography is the investigation of choice for imaging of vegetations on an endocavitary pacing lead (2). Open intracardiac removal of retained pacing electrodes with or without use of cardiopulmonary bypass is a safe procedure without major complications. It is mandatory for all infected pacing electrodes that cannot be extracted by closed methods (9). Complete explanation is essential for a complete recovery of this infection (2).


(1.) Tascini C, Bongiorni MG, Gemignani G, Soldati E, Leonildi A, Arena G, et al. Management of cardiac device infections: A retrospective survey of a non surgical approach combining antibiotic therapy with transvenous removal. J Chemother 2006; 18:157-63.

(2.) Victor F De Place C, Camus C, Le Breton H, Leclercq C, Pavin D, et al. Pacemaker lead infection, echocardiographic features, management, and outcome. Heart 1999;81:82-7.

(3.) Kouvosis N, Lazaros AG, Christoforatou EG, Deftereos S, Petropoulou-Milona D, Lelekis M, et al. Acremonium Species pacemaker site infection. Hellenic J Cardiol 2003; 44:83-7.

(4.) Chamis AL, Peterson GE, Cabell CH, Corey GR, Sorrentino RA, Greenfield RA et al. Staphylococcus aureus bacteremia in patients with permanent pacemakers or implantable cardioverter-defibrillators. Circulation 2001; 104:1029-33.

(5.) Cacoub P, Leprince P, Nataf P, Hausfater P, Dorent R, Wechsler B, et al. Pacemaker infective endocarditis. Am J Cardiol 1998; 82:480-4.

(6.) Jassal DS, Weyman AE. Infective endocarditis in the era of intracardiac devices: an echocardiographic perspective. Rev Cardiovasc Med 2006; 7:119-29.

(7.) Arber N, Copperman Y, Schapiro JM, Schapiro JM, Meiner V, Lossos IS, et al. Pacemaker endocarditis. Report of 44 cases and review of the literature. Medicine 1994; 73: 299-305.

(8.) Karchmer AW, Longworth DL. Infections of intracardiac devices. Cardiol Clin 2003;21:253-71.

(9.) Niederhauser U, von Segesser LK, Carrel TP Laske A, Bauer E, Schonbeck M, et al. Infected endocardial pacemaker electrodes: successful open intracardiac removal. Pacing Clin Electrophysiol 1993; 16:303-8.

Ali Gurbuz, Murat Yesil*, Ufuk Yetkin, Nursen Postaci*, Ismail Yurekli, Erdinc Ankan*

From Clinic of Cardiovascular Surgery and *1. Cardiology Clinic, Izmir Ataturk Training and Research Hospital, Izmir, Turkey

Address for Correspondence/Yazisma Adresi: Dr. Ufuk Yetkin, Izmir Ataturk Training and Researh Hospital, Clinic of Cardiovascular Surgery Izmir, Turkiye Phone: +90 232 244 44 44 - 2448 Fax: +90 232 243 48 48 E-mail:
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Title Annotation:Case Reports/Olgu Sunumlari
Author:Gurbuz, Ali; Yesil, Murat; Yetkin, Ufuk; Postaci, Nursen; Yurekli, Ismail; Arikan, Erdinc
Publication:The Anatolian Journal of Cardiology (Anadolu Kardiyoloji Dergisi)
Date:Jun 1, 2009
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