Peri‑electrode abscess in lead‑dependent infective endocarditis resulting in high peri‑interventional risk related to septic embolism

325 A 53‐year‐old man presented to an outpatient clinic with fever of unknown origin and anemia. His past medical history was remarkable for hy‐ pertension, diabetes mellitus, ST‐segment eleva‐ tion myocardial infarction 3 years earlier, compli‐ cated by severe left ventricular systolic dysfunc‐ tion (left ventricular ejection fraction, 32%), im‐ plantable cardioverter‐defibrillator implantation 2 years earlier, and elective percutaneous coronary intervention of the circumflex coronary artery with drug‐eluting stent implantation 6 months earlier. He complained of chills, spiking fevers up to 41oC with dizziness, malaise, and weakness for 1 month despite use of broad‐spectrum antibi‐ otics. So far, no potential inflammation site has been identified in diagnostic work‐up. On physical examination, the patient was pale and cachectic. No heart murmurs or signs of peripheral microvascular thrombosis – Jane‐ way lesions or Osler nodes – were present. Blood tests revealed elevated inflammatory markers (C‐reactive protein, 236 mg/l; procalcitonin, 33 ng/ml; leukocytosis, 11,400/mm3 with neu‐ trophilia; and normocytic hypochromic anemia with hemoglobin levels of 9.7 g/dl). Transesopha‐ geal echocardiography showed multiple large veg‐ etations attached to the ventricular lead (FIGURE 1A), the largest of 21 × 13 mm with adjacent multiple echolucent spaces at the base, resembling medusa (FIGURE 1B) and suggesting an abscess. No patent foramen ovale (PFO) was observed. Empiric broad‐ ‐spectrum antibiotics (vancomycin and rifampi‐ cin) were administered just after blood cultures were drawn, but the patient remained febrile (up to 41oC) with shaking chills and sweats. On the fifth day of hospitalization, transve‐ nous lead extraction (TLE) was performed under general anesthesia with cardiosurgical back‐up. An electrode with vegetation was removed using a lead extraction system (Cook Medical Inc., Unit‐ ed States) with 2 large‐size (white) telescopic poly‐ propylene Byrd’s dilators (FIGURE 1C), wide enough to pull out the largest, fibrous part of the vegeta‐ tion through the lumen (FIGURE 1D). Lead manipu‐ lation resulted in releasing peri‐lead abscess con‐ tent causing transient hypotension (40/0 mmHg) and desaturation suggestive of pulmonary em‐ bolization with infective material. The vegeta‐ tion culture was positive for Staphylococcus hominis. There was right‐sided pneumonia following TLE. The patient gradually improved and was dis‐ charged after 1 month of antibiotic therapy in a good clinical condition. TLE is associated with a significant risk, includ‐ ing pulmonary1,2 and paradoxical embolism.3 In contrast to a more detailed approach in left‐ ‐sided endocarditis, echocardiographic criteria for risk assessment in peri‐TLE embolization are less well‐defined by the current guidelines.4 This is the first report of a peri‐lead abscess with subsequent peri‐interventional emboliza‐ tion to have demonstrated that, in addition to size, morphological features shown on trans‐ esophageal echocardiography (TEE) (in partic‐ ular, nonuniform vegetation texture with echo‐ lucent appearance) indicate higher peri‐TLE risk. In this context, preprocedural diagnosis of PFO is mandatory to be aware of potential paradox‐ ical embolism.5 Correspondence to: Edyta Stodółkiewicz, MD, Centrum Interwencyjnego Leczenia Chorób Serca i Naczyń, Krakowski Szpital Specjalistyczny im. Jana Pawła II, ul. Prądnicka 80, 31-202 Kraków, Poland, phone: +48-12-614-35-01, fax: +48-12-614-30-47, e-mail: edytastod@gmail.com Received: May 5, 2013. Revision accepted: May 20, 2013. Conflict of interest: none declared. Pol Arch Med Wewn. 2013; 123 (6): 325-326 Copyright by Medycyna Praktyczna, Kraków 2013 CLINICAL IMAGE