Case Report

A 73 year old Caucasian male with dilated cardiomyopathy, atrial fibrillation, and an automated implantable cardioverter defibrillator (AICD) placed 1 year ago presented with implant side soreness and methicillin resistant staphylococcus aureus (MRSA) bacteremia. EKG showed multiple runs of nonsustained ventricular tachycardia (NSVT). Transesophageal echocardiogram revealed a 4.2 cm size abscess on tricuspid valve ring at the site of electrode implantation (Figure ).

Treatment of this abscess would have required surgical removal of leads during extracorporeal circulation. During the course of his hospitalization the patient developed lower gastrointestinal bleed and was found to be having a colonic carcinoma. The patient's general condition precluded anesthesia and surgery and he was treated with vancomycin and was planned for hospice care. Unfortunately the patient expired before hospice was set up.

The incidence of infective endocarditis after permanent endocardial pacemaker (PM) implantation varies 0.13% to 7% in the reported literature ₁ . Staphylococcus aureus, and Staphylococci epidermis account for upto 80% of the acute cases ₂ This patient had his AICD placed more than 1 year ago. The high rate of relapse associated with PM - related septicemia usually necessitates the removal of whole pacemaker system ₃. Percutaneous removal can be tried in patients with vegetations <10 mm but patients with vegetations >10 mm and complications require surgical removal during extracorporeal circulation2. Appropriate antibiotics need to be administered for 6 weeks after removal of leads

Figure 1

Figure 1: Trans esophageal Echocardiogram at Tricuspid valve projection. A 4.2 cm size spherical mass with lobulated surface located at tricuspid valve ring bordering on epicardial surface near right atrial appendage adjacent to non-coronary aortic cusp

Correspondence to

Prakash Chandra, Dept of Medicine, One Baylor Plaza, Houston, TX 77054 404-316-7462, Email: chandra@bcm.tmc.edu