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| A PICTURE IS WORTH A THOUSAND WORDS |
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| Year : 2023 | Volume
: 24
| Issue : 1 | Page : 63-64 |
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Cardiac resynchronization therapy vegetations
Abdel Haleem Shawky Hamada, Ahmed Mohammed Al-Maghraby, Smitha Anilkumar
Non-Invasive Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| Date of Submission | 19-Dec-2022 |
| Date of Acceptance | 23-Jan-2023 |
| Date of Web Publication | 23-Feb-2023 |
Correspondence Address:
Dr. Abdel Haleem Shawky Hamada
Heart Hospital, Hamad Medical Corporation, P. O. Box 3050, Doha
Qatar
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/heartviews.heartviews_124_22
How to cite this article:
Hamada AH, Al-Maghraby AM, Anilkumar S. Cardiac resynchronization therapy vegetations. Heart Views 2023;24:63-4 |
A 71-year-old male patient presented to the emergency department with a history of headache, fever, and dizziness of 1-week duration. He was on home isolation as the COVID polymerase chain reaction was positive with a cycle threshold value of 21.79 for 1 week. The patient has past medical history of diabetes mellitus Type II, end-stage renal disease on hemodialysis, coronary artery disease, status postcoronary artery bypass grafting in 2008, and ischemic cardiomyopathy (9/2020) postimplantable cardioverter defibrillators insertion in 2010 which was upgraded to cardiac resynchronization therapy defibrillator.
The patient has spikes of fever during his hospital stay. As a part of the septic workup, a blood culture was sent, which came positive for methicillin-resistant Staphylococcus aureus. Hence, transesophageal echocardiography (TEE) was recommended to rule out vegetation.
TEE showed multiple highly mobile cauliflower vegetation seen attached to the coronary sinus lead at its orifice to the right atrium.
It measured 1.2 cm × 0.6 cm. Another larger vegetation was seen on the atrial surface of the septal leaflet of the tricuspid valve at its attachment with the right ventricular (RV) lead and measured 1.7 cm × 0.8 cm in size [Figure 1]a. Another two highly mobile vegetations seen at the attachment of right atrial (RA) lead to RA-free wall and measured 1.0 cm × 0.5 cm and 0.9 cm × 0.4 cm in size [Figure 1]b. The RV lead was seen impinged in the septal-posterior commissure of the tricuspid valve.
The culture was repeated after 4 weeks of antibiotics which showed bacteremia clearance.
Follow-up TEE showed no vegetation in the coronary sinus lead and RV lead [Figure 2]a and a reduction in the size of the vegetation in RA lead [Figure 2]b. The patient was discharged after 6 weeks from the hospital. He was kept on long-term septrin and rifampicin as the device was not removed.
The patient was re-admitted two months later for device removal, and wound debridement, and underwent CRT-D box and LV lead removal, and wound debridement. RV and RA leads were capped and left in place (old leads). The patient was discharged on the 2nd day after the procedure.
Intracardiac devices endocarditis is the most severe form of endocarditis and is associated with higher mortality.[1] The estimated rate of infection after permanent endocardial implantation is between 1% and 2%.[2] The prevalence of endocarditis in CRT recipients is almost 5% within 3.5 years postimplantation.[3] Coagulase-negative Staphylococci accounts for 70% of cases. Definite diagnosis is particularly difficult. Echocardiography and blood culture are the cornerstone of diagnosis.
Long-term proper antibiotics and total removal of the infected device are the definite treatment.[4] Transvenous lead extraction is the gold standard, also in the presence of large vegetation. Complications such as destruction of the tricuspid valve, septic pulmonary embolism, and consecutive abscess-forming pneumonia can occur if treatment for lead infections is delayed.[5]
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
 References | |  |
| 1. | Sohail MR, Uslan DZ, Khan AH, Friedman PA, Hayes DL, Wilson WR, et al. Management and outcome of permanent pacemaker and implantable cardioverter-defibrillator infections. J Am Coll Cardiol 2007;49:1851-9.  |
| 2. | Klug D, Balde M, Pavin D, Hidden-Lucet F, Clementy J, Sadoul N, et al. Risk factors related to infections of implanted pacemakers and cardioverter-defibrillators: Results of a large prospective study. Circulation 2007;116:1349-55. |
| 3. | Athan E, Chu VH, Tattevin P, Selton-Suty C, Jones P, Naber C, et al. Clinical characteristics and outcome of infective endocarditis involving implantable cardiac devices. JAMA 2012;307:1727-35. |
| 4. | Camus C, Leport C, Raffi F, Michelet C, Cartier F, Vilde JL. Sustained bacteremia in 26 patients with a permanent endocardial pacemaker: Assessment of wire removal. Clin Infect Dis 1993;17:46-55. |
| 5. | Ruttmann E, Hangler HB, Kilo J, Höfer D, Müller LC, Hintringer F, et al. Transvenous pacemaker lead removal is safe and effective even in large vegetations: An analysis of 53 cases of pacemaker lead endocarditis. Pacing Clin Electrophysiol 2006;29:231-6. |
[Figure 1], [Figure 2]
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