Asian Cardiovasc Thorac Ann 2007;15:64-65
© 2007 Asia Publishing EXchange Ltd
Malplacement of a Pacemaker Lead — A Rare Cause for Aortic Valve Endocarditis
K Matschke, MD,
Sm Tugtekin, MD,
K Alexiou, MD,
M Knaut, MD,
Jw Park, PhD,
M Schulze, MD1
Department of Cardiac Surgery
1 Department of Cardiology, Heart Center Dresden University Hospital, Dresden, Germany
For reprint information contact: Klaus Matschke, MD Tel: 49 351 450 1809 Fax: 49 351 450 1707 Email: K.Ploetze{at}herzzentrum-dresden.com, Department. of Cardiac Surgery, University Hospital, Heart Center Dresden Ltd, Fetscherstr. 76, D-01307 Dresden, Germany.
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ABSTRACT
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Infective endocarditis of native valves following pacemaker implantation is rare but can be associated with serious complications, approaching a mortality of up to 25%.1 Recent publications report a frequency of pacemaker related endocarditis between 0.5 and 7%.2 Due to anatomical reasons the tricuspid valve is mostly affected in these patients, with involvement of the left heart valves usually secondary. We report an incidence of native aortic valve endocarditis due to a misplaced pacemaker lead into the left heart.
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INTRODUCTION
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Infective endocarditis of native valves following pacemaker implantation is rare, but can be associated with serious complications reaching a mortality up to 25 %.1 Recent publications report a frequency of 0.5 to 7 % of pacemaker related endocarditis.2 Due to anatomical reasons tricuspid valve is mostly affected in these patients. Affection of left heart valves is most often secondary. We report a native aortic valve endocarditis due to a misplaced pacemaker lead into the left heart.
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CASE STUDY
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An 82-year-old male patient was referred to our institution with a diagnosis of aortic valve endocarditis on transthoracic echocardiography (TTE). For the last four weeks the patient had suffered from fever, malaise, weight loss, night sweats, and a transient cerebral ischemic attack. A ventricular pacemaker had been implanted in another hospital several months previously. The implantation was described as uneventful and pacemaker controls were normal.
On admission, pacemaker EKG showed a right bundle branch blockage. Transesophageal echocardiography (TEE) confirmed the diagnosis of aortic valve endocarditis with huge vegetation on the right aortic cusp (Figure 1
). In addition a misplaced pacemaker lead was identified in the left ventricle in close relation to the aortic valve causing aortic valve insufficiency. Microbiology was positive for Staphylococcus epidermidis. Antibiotic therapy with rifampicin, vancomycin, and gentamycin was initiated and the patient was referred for surgery.
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Figure 1: Transesophageal echocardiography view of the pacemaker lead in the left ventricle. LA = left atrium; LV = left ventricle; RCC = right coronary cusp.
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A possible source or incidence of hematogenous seeding could not be evaluated in the patient’s history.
Intraoperative inspection confirmed the presence of a pacemaker lead inadvertently inserted in the left ventricle (Figure 2). The aortic valve showed huge vegetation adhering to the right aortic cusp with the pacemaker lead compressing the cusp. The pacemaker lead was mobilized and completely removed from the ascending aorta. After valve resection a biologic valve replacement was performed, the pacemaker pocket was inspected, and the complete system was removed. There were no signs of pacemaker pocket infection.
The postoperative course was uneventful. The patient was in stable sinus rhythm with no need for implantation of a new pacemaker, and was discharged two weeks after surgery. At the six month follow-up the patient was still in sinus rhythm and in good clinical status.
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DISCUSSION
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Infective endocarditis associated with pacemaker implantation has become rare since the introduction of antibiotic prophylaxis. In general, pacemaker related endocarditis is suspected in cases of fever (85%) and local infection signs within the pacemaker pocket (50%). Staphylococcus species are the pathogens most often isolated.3 Clinical or radiological evidence of pulmonary involvement, due to embolization, is observed in 30 to 40% of all patients.3 Diagnosis is guided by the clinical course of the patient and confirmed with echocardiography. Transesophageal echocardiography is essential.
Therapy is based on the principles of endocarditis treatment including long-term antibiotic treatment, radical surgical debridement of infected areas and removal of the complete pacemaker system. Native valve endocarditis related to pacemaker implantation mostly affects the tricuspid valve and in rare cases the aortic and mitral valves.4 In this case, aortic valve endocarditis was most likely due to the pacemaker lead being incorrectly introduced via the subclavian artery and aorta into the left ventricle. The pacemaker lead induced mechanical endocardial lesions and subsequent blood flow disturbances through the aortic valve, thus creating a basis for endocarditis.
Case reports of inadvertently placed pacing leads have been published in the literature with the malplacement remaining undetected for years.5,6 However, in the reported cases the leads were always placed transvenously through a patent foramen ovale into the left ventricle. To our knowledge this pathway of aortic valve endocarditis after pacemaker implantation has not been described before.
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REFERENCES
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- Cacoub P, Leprince P, Nataf P, Hausfater P, Dorent R, Wechsler B, et al.Pacemaker infective endocarditis. Am J Cardiol 1998;82:480–4.[Medline]
- Erdinler I, Okmen E, Zor U, Zor A, Oguz E, Ketenci B, et al. Pacemaker related endocarditis: analysis of seven cases. Jpn Heart J 2002;43:475–85.[Medline]
- Klug D, Lacroix D, Savoye C, Goullard L, Grandmougin D, Hennequin JL,et al. Systemic infection related to endocarditis on pacemaker leads: clinical presentation and management. Circulation 1997;95:2098–107.[Abstract/Free Full Text]
- Funck R, Herzum M, Barth PJ, Bethge C, Maisch B. Aortic and mitral valve endocarditis after infection of the pacemaker pocket. Herz 1994;19:149–51.[Medline]
- Van Gelder BM, Bracke FA, Oto A, Yildirir A, Haas PC, Seger JJ, et al. Diagnosis and management of inadvertently placed pacing and ICD leads in the left ventricle: a multicenter experience and review of the literature. Pacing Clin Electrophysiol 2000;23:877–83.[Medline]
- Ciolli A, Trambaiolo P, Lo Sardo G, Sasdelli M, Palamara A. Asymptomatic malposition of a pacing lead in the left ventricle: the case of a woman untreated with anticoagulant therapy for eight years. Ital Heart J 2003;4:562–4.[Medline]
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ABSTRACT
INTRODUCTION
