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Management of Septic Emboli in the Course of Lead Dependent Infective Endocarditis – Case Report Czyli TLE nie zawsze oznacza koniec leczenia. „Ucieknięte” wege ktoś musi wyciągnąć z krążenia płucnego Andrzej Kutarski ¹, Jerzy Śpikowski ², Andrzej Tomaszewski ¹, Ewa Mroczek ², Elżbieta Czekajska-Chehab ³, Marek Czajkowski (4), Krzysztof Oleszczak ¹, Edyta Stodółkiewicz ¹, Romuald Cichoń (5). 1. Department of Cardiology, Medical University of Lublin 2. Department of Cardiology, State Hospital in Wroclaw 3. Department of Radiology, Medical University of Lublin 4. Department of Cardiosurgery, Medical University of Lublin 5. Silesian Heart Disease Center „Medinet“ in Wroclaw Wroclaw
Andrzej Kutarski
Polstim 2013
Lublin (a_kutatski@yahoo.com (a_kutatski@yahoo.com))
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26 years old male with past medical history of corrected Transposition of Great Vessels (TGV) in NYHA class I and congenital complete heart block was referred with severe LDIE. At age 15 (11 years ago) he had implanted conventional pacing system DDD (two passive electrodes: to right atrium appendage and to apex of right ventricle, both Pacesetter Tendril, also pacemaker Pacesetter Trilogy DR+), leaving longer loops of leads in right atrium due to expected growth of child’s body (Fig. 1). Retrospectively most likely this fact was crucial for fateful effects in the future. At age 17 ventricular lead was repositioned and at age 22 pacemaker was routinely replaced due to battery depletion (ERI). One year ago a repair of damaged ventricular lead - excision of damaged segment in pocket and application of adapter Biotronik A1N was performed
Initially the patient presented with fever up to 39ď‚°C, chills and vegetation 1.3 x 3.1 cm attached to ventricular lead in TEE. The laboratory signs of inflammation were discreet: ESR of 10, leucocytosis 11.000, CRP 28.2 mg/l. Expecting difficulties with leads extraction the patient was transferred to reference center. Immediately after admission to our center angio-CT was performed showing spontaneous dislocation of vegetation with complete occlusion of inferior lobar artery in the left lung. TEE confirmed presence of smaller ( 1,3 x 1,8 cm ) vegetations: one in SVC ostium and second attached to ventricular lead (Fig. 3,4). The control ABG shown acid-base disturbances - pH 7.43, pCO2 33 mm Hg, pO2 56 mmHg, saturation O2 90.3%.
ECG-MSCT – arterial phase. In axial view (A) and oblique reconstruction (B) visible clot causing total occlusion of the lumen of left low-lobar artery (black long arrow), presence of numerous enlarged mediastinal lymph nodes (short white arrows) and changed anatomical relations of aorta and pulmonary trunk (Ao,
PT)
ECG-MSCT - late phase. Clots or vegetations surrounding leads visible in distal part of SVC.
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TEE after admission to reference center. Short arrows: small vegetations attached to ventricular lead. Big arrows: big vegetation in the ostium of superior vena cava.
Total extraction of the pacing system was performed with mechanical system of green telescopic Byrd dilatators (Cook Co.) was used. We found outflow of purulent content from the electrode during insertion of a guide wire into the lead. The leads were completely extracted. We found multiple lead abrasions in the intracardiac parts of leads – localized in places related to their dynamic contact in radiologic imaging Lead cultures were taken which shown no growth.
Purulent content outflow from extracted lead.
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Transvenosus lead extraction using Byrd dilatators. For lead extraction the separation of connective tissue bridges with Byrd catheters up to SVC was necessary. Intracardiac parts of leads were not damaged during extraction procedure.
Removed leads. Abrasions of external silicone sheath of both of them with spiral metal conductor exposure in the place of mutual friction and connective tissue are visible
After arrangement the patient was transferred back to his local hospital for further management since his discharge TEE has shown a thrombus (or a vegetation) 2.9 x 1.0 cm at the orifice of VCS with acceleration of flow
TEE performed on next day after leads extraction. Only one big vegetation?/thrombus? remained in the ostium of superior cava vein (arrows).
Efforts to recanalize the plug in inferior lobar branch of left pulmonary artery were unsuccessful using guide wires and various catheters. Control angio-CT confirmed remaining plug. Antibiotic therapy was continued (Vancomycin and Gentamycin). For the next three weeks the patient remained febrile with laboratory features of inflammation. CRP level fluctuated in the range of 38,7 – 103,3 mg/l. Control TEE confirmed presence of vegetation at the ostium of VCS of 3.2 x 1.0 cm. Serial performed angio-CT visualized thrombi/vegetations reaching much higher level in VCS and presence of other embolic material in anonymous vein (left brachiocephalic vein) and total obliteration of left inferior lobar artery (5.3 x 1.6 x 1.8 cm) with maintenance of blood flow into inferior lobe of left lung by bronchial arteries, not showing other embolic material in right atrium and right ventricle. Described findings were associated with enlargement of mediastinal lymph nodes up to 2.6 x 1.2 cm ECG-MSCT – arterial phase. In axial view still visible clot (A) closing whole lumen of left lowlobar artery (arrow), presence of numerous enlarged mediastinal and chilus lymph nodes and infarctive changes in inferior lobe of left www.usuwanieelektrod.pl lung (small arrows). a_kutarski@yahoo.com
Taking under consideration ineffectiveness of conservative management (various antibiotic regimens with: vancomycin and gentamycin; rifampicin, ceftazidime and teicoplanin; linezolid, meropenem and ketoconazole) resulting from presence of septic thrombi in SVC and at the branch of left pulmonary artery, final decision for surgical removal of septic embolic material from SVC and left inferior lobar artery was taken followed by implantation of epicardial permanent pacing system. Vegetation from ostium of SVC was removed and calcified fibrous tissue extending from SVC ostium to orifice of common carotid vein and anonymous vein was removed. Subsequent opening of pulmonary trunk and incision of left pulmonary artery up into its division allowed for visualization of embolic material, which thereafter was removed. It was a plug of 9 cm long embolic material
Embolic masses (vegetation and probably secondary mould clots) removed during surgery from low-lobar branch of left pulmonary artery
Based on this experience one comment can be made: however TEE constitutes gold diagnostic standard in LDIE, computerized tomography (angio-CT) proved to be as important tool allowing not only to visualize the vegetation, which disappeared from echocardiographic field by dislodging into pulmonary artery, but also to evaluate other potential embolic material and the patency of SVC. We postulate to include computerized tomography (angio-CT) into standards of diagnosis in LDIE together with TEE and to appreciate the significance of LDIE as an underestimated medical problem in the medicine of XXI century
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Konkluzje bardziej praktyczne: •Jak najszybsze usunięcie układu to podstawa leczenia LRIE •Bywa, że spora wegetacja ucieknie spontanicznie do krążenia płucnego przed TLE •Bywa, że spora część wegetacji zostanie związana ze ścianą serca / VCS pomimo TLE •Próby przejścia przez wege blokującą tętnicę płatową raczej mają małe szanse powodzenia (próbowałem, ale bez powodzenia) •Widok tego co usunął kardiochirurg, ukazuje ograniczone możliwości działań przezskórnych •Dokończenie porządków po „kardiologach” to bardzo ważna rola kardiochirurgii •Nie da się przecenić angio-CT w leczeniu mocno pokomplikowanego przebiegu LRIE
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