Lead-dependent infective endocarditis in a patient with five old pacemaker leads – less invasive management

Introduction

Lead-dependent infective endocarditis (LDIE) and pacing system dependent sepsis are very serious complications of permanent heart pacing [1, 2]. The main rule, constant for many years, is complete system removal, including leads and even fragments of them [3-6]. In the first years of permanent intracardiac pacing in the 1960s to ’70s, leads were evacuated by cardiac surgeons, just with simple traction through the opened right atrium. Recently, the average age of a lead body being removed is significantly older (15-20 years or older) and patients usually have multiple leads.

Every lead residing in the heart cavities and venous system, after some time, becomes covered by endothelium (endothelialisation) and later connected to the walls of veins and heart and then surrounded with joint tissue (tunnelisation). Tissue joints can fix a lead to the wall or to other leads, excluding part of the vein lumen. In the case of mul-

tiple leads it can even cause complete vein obstruction with opening of collateral circulation, if it is present [7, 8].

The connective tissue scar usually makes it impossible to remove a lead by simple traction and different cutting catheters working around a lead are necessary for its liberation and complete removal. It has been proven that the strongest connections are formed in the subclavian, anonymous and beginning of the superior cava veins. Their calcification makes the procedure of transvenous lead extraction (TLE) even more difficult [7, 8]. TLE of leads implanted into the cardiac vein system seems to be very risky but numerous single centre experiences seem to deny a consensus [9-11].

Case report

An 80-year-old patient was treated from 1997 with permanent pacing at first with DDD pacing but the atrial lead was located in the coronary sinus (CS) and the standard passive one (ventricular) in the right ventricle apex. Due to severe interatrial block with recurrent atypical atrial flutter and worsening of left ventricle contractility (low ejection fraction [EF]) the system was upgraded to four-chamber pacing in 2002. Two new leads, unipolar into the right atrium appendage (RAA) and unipolar into the postero-lateral cardiac vein (Corox LV 75 UP), were implanted. Unfortunately, 3 years later chronic atrial fibrillation occurred and increase of pacing threshold on the RVA lead appeared. A new RV lead was implanted and both atrial leads and one older ventricular lead were abandoned. In spite of permanent AF, due to pacemaker dependence the patient remained during the next 6 years in NYHA class II with EF 50% having 100% simultaneous ventricular pacing. Recently, the patient primarily was admitted for unit replacement but due to elevated CRP level (> 30 mg/l) TEE was performed. Because no vegetation was observed and CRP values decreased to

18 mg/l (procalcitonin was in the normal range), an attempt of simple unit replacement was made. According to the first operator’s report, the skin over the (submuscular) pocket was absolutely normal. The skin incision released an outflow of purulent fluid before submuscular pocket opening. Due to the presence of numerous old, ingrown leads (Fig. 1),

the incision was closed and the patient was referred to

the authors’ team for considering the possibility of TLE.

The idea to apply suction drainage of the infected wound did not occur at the time, unfortunately.

Various organisational factors delayed lead extraction for two weeks. During this time the patient was without fever but 3 blood cultures were positive and revealed the growth of coagulase-negative meticillin-resistant Staphylococcus epidermidis and it was identical to the culture from the pocket swab. The CRP level increased to 80 mg/l. Leukocytosis was only 8 000. As late as obtaining the microbiological examination of pocket pus the patient was treated with clindamycin; afterward she received vancomycin.

The diagnosis of chronic pocket infection with infection distension was made. The patient was considered for a cardiac surgical procedure but the patient’s age, presence of diabetes, overweight and possibility of strong lead connection with systemic and cardiac vein walls indicated numerous problems both during the operation and in

the postoperative period.

The chest fluoroscopy revealed presence of 5 leads, including 2 leads in CS, and venography revealed complete occlusion of subclavian and anonymous vein.

As the first step of the procedure, a standard temporary pacing designed lead was introduced via the femoral vein due to pacemaker dependence.

As the first one – RAA lead was extracted (Fig. 2A, B) using Byrd dilators. As the second – the CS lead designed for LA pacing (C, D).

The third lead being extracted was the old abandoned BP RVA lead (Fig. 3A, B). During the procedure via an empty Byrd dilator standard guidewires were introduced to keep venous access. Due to the known high risk of dislodgement of a lead designed for temporary pacing and serious pacemaker dependence, the new additional lead for temporary pacing was implanted via an empty Byrd dilator (this lead appears in figure 3 C and D with the tip located in the RVOT position). As the fourth one, the LV pacing designed lead was to have been extracted, but a very strong connective tissue scar appeared in the CS ostium region embracing two leads – the LV lead and RVA lead. The leads could not be separated with a single Byrd dilator (D).

We stopped LV lead extraction and the previously functional RVA lead was extracted with a Byrd dilator (Fig. 4A). Simultaneous or alternate working with two Burst dilators (they work as scissors) permitted separation of both leads from the connective tissue scar and successful extraction of them (B, C). Finally the temporary pacing lead was removed and the patient remained on a prolonged temporary pacing lead for the next two weeks until implantation

of the new system on the right side of the chest.

Drainage of the pacemaker pocket was performed and the procedure was finished. The patient was successfully treated with vancomycin for the next two weeks. The con-

trol echocardiography did not show the appearance of ve-

getation and laboratory findings normalized gradually.

The temporary pacing system allows the patient to leave bed and move in the department area.

Discussion

The valid guidelines of LDIE treatment provide only four indications for surgical treatment: huge vegetation (2-3 cm), coexisting heart pathology requiring surgical correction, failure or complications of percutaneous lead removal [3, 4]. In our case the mentioned indications were not present. All leads were extracted bodily transvenously, without complications. The whole procedure duration was relatively long, over 3 hours, but it was uncomplicated and successful. The most worrying and difficult moment of the des-

cribed procedure was the management of two strongly connected leads, and it was solved with the technique, not described previously, of simultaneous liberation of both connected leads. Another interesting point was prolonged pacing using a standard screw-in lead, designed for permanent pacing, connected with the explanted pacemaker. The lead was inserted via a Byrd dilator after extracted lead removal in spite of complete venous system occlusion. It liberates the pacemaker dependent patient from permanent staying in bed and makes the prolonged temporary (weeks) pacing more sure and safe. This pacing mode allows one to keep the opposite chest side clear for implantation of a new system after healing of the infection. The role of the cardiac surgeon in treatment of permanent pacing complications still remains crucial, because urgent treatment of great vein tears may be more difficult but (fortunately rarely) necessary [12, 13]. In the authors’ experience (903 TLE procedures during 5 years) only 3 patients needed surgery, due to cardiac tamponade (0.3%). Rapid amplification of the infection after unnecessary pocket skin incision seems to be surprising; the duty of the operator was to apply suction drainage of the wound, but he was probably alarmed by the X-ray findings, including the age, number and location of leads. Proper but standard antibiotic therapy before obtaining the blood culture result did not prevent the most serious complication – sepsis.

Conclusions

The case is a good illustration of the possibilities of TLE at present and modern management of permanent pacing system infection. The role of the cardiac surgeon is now more to provide conscious and undelayed management

of possible complications. Patients without indications mentioned in recent guidelines should not be referred to cardiac surgeons.

References

1. Małecka B, Kutarski A. Lead-dependent infective endocarditis: an old problem, a new name. Cardiol J 2010; 17: 205-210.

2. Mazurek M, Grzegorzewski B, Kargul W. [Infections associated with permanent pacemakers and implantable cardioverters-defibrillators]. Kardiol Pol 2009; 67: 305-309.

3. Habib G, Hoen B, Tornos P, Thuny F, Prendergast B, Vilacosta I, Moreillon P,

de Jesus Antunes M, Thilen U, Lekakis J, Lengyel M, Müller L, Naber CK, Nihoyannopoulos P, Moritz A, Zamorano JL; ESC Committee for Practice Guidelines. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): the Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the International Society of Chemotherapy (ISC) for Infection and Cancer. Eur Heart J 2009; 30: 2369-2413.

4. Baddour LM, Epstein AE, Erickson CC, Knight BP, Levison ME, Lockhart PB, Masoudi FA, Okum EJ, Wilson WR, Beerman LB, Bolger AF, Estes NA 3rd, Gewitz M, Newburger JW, Schron EB, Taubert KA; American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; Council on Cardiovascular Disease in Young; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Nursing; Council on Clinical Cardio-

logy; Interdisciplinary Council on Quality of Care; American Heart Association. Update on cardiovascular implantable electronic device infections and their management: a scientific statement from the American Heart Association. Circulation 2010; 121: 458-477.

5. Wilkoff BL, Love CJ, Byrd CL, Bongiorni MG, Carrillo RG, Crossley GH 3rd, Epstein LM, Friedman RA, Kennergren CE, Mitkowski P, Schaerf RH, Waz-

ni OM; Heart Rhythm Society; American Heart Association. Transvenous lead extraction: Heart Rhythm Society expert consensus on facilities, training, indications, and patient management: this document was endorsed by the American Heart Association (AHA). Heart Rhythm 2009; 6: 1085-1104.

6. Love CJ, Wilkoff BL, Byrd CL, Belott PH, Brinker JA, Fearnot NE, Friedman RA, Furman S, Goode LB, Hayes DL, Kawanishi DT, Parsonnet V, Reiser C, Van Zandt HJ. Recommendations for extraction of chronically implanted transvenous pacing and defibrillator leads: indications, facilities, training. North American Society of Pacing and Electrophysiology Lead Extraction Conference Faculty. Pacing Clin Electrophysiol 2000; 23: 544-551.

7. Kozłowski D, Dubaniewicz A, Koźluk E, Grzybiak M, Krupa W, Kołodziej P, Pazdyga A, Adamowicz-Kornacka M, Walczak E, Walczak F. The morphological conditions of the permanent pacemaker lead extraction. Folia Morphol 2000; 59: 25-29.

8. Esposito M, Kennergren C, Holmström N, Nilsson S, Eckerdal J, Thomsen P. Morphologic and immunohistochemical observations of tissues surrounding retrieved transvenous pacemaker leads. J Biomed Mater Res 2002; 63: 548-558.

9. Williams SE, Arujuna A, Whitaker J, Shetty AK, Bostock J, Patel N, Mobb M, Cooklin M, Gill J, Blauth C, Bucknall C, Hamid S, Rinaldi CA. Percutaneous lead and system extraction in patients with cardiac resynchronization therapy (CRT) devices and coronary sinus leads. Pacing Clin Electrophysiol 2011; 34: 1209-1216.

10. Baranowski B, Yerkey M, Dresing T, Wilkoff BL. Fibrotic tissue growth into the extendable lobes of an active fixation coronary sinus lead can complicate extraction. Pacing Clin Electrophysiol 2011; 34: e64-65.

11. Hamid S, Arujuna A, Khan S, Ladwiniec A, McPhail M, Bostock J, Mobb M, Patel N, Bucknall C, Rinaldi CA. Extraction of chronic pacemaker and defibrillator leads from the coronary sinus: laser infrequently used but required. Europace 2009; 11: 213-215.

12. Kutarski A, Jendrej J. Współpraca kardiologa z kardiochirurgiem przy leczeniu poważnych powikłań infekcyjnych stymulacji stałej. Folia Cardiologica Excerpta 2009; 4: 136-141.

13. Kutarski A, Czajkowski M, Jendrej J. Treatment of permanent pacing infective complications in the reference centre. Mandatory cooperation of cardiologist and cardiac surgeon. Kardiochir Torakochir Pol 2010; 7: 376-382.