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Chronic cor pulmonale: a rare complication of undiagnosed pacemaker lead endocarditis
International Journal of Cardiology 96 (2004) 119 – 120 www.elsevier.com/locate/ijcard
Letter to the Editor
Chronic cor pulmonale: a rare complication of undiagnosed pacemaker lead endocarditis Nicolas Mansencal a,*, Thomas Lavergne a, Pierre Bordachar a, Eric Abergel a, Jean-Yves Le Heuzey a, Franc¸oise Hidden b, Louis Guize a b
a Department of Cardiology, AP-HP, Hoˆpital Europe´en Georges Pompidou, Paris, France Department of Cardiology, AP-HP, Institut du Cœur, Hoˆpital la Pitie´-Salpe´trie`re, Paris, France
Received 29 December 2002; accepted 2 April 2003
Abstract Pacemaker lead infection is a rare life-threatening complication of permanent transvenous pacing. We describe the case of a young man who suffered recurrent undiagnosed septic pulmonary embolisms from pacemaker lead vegetations inducing chronic cor pulmonale with major pulmonary arterial hypertension. The potential complications of transvenous pacing and the systematic use of transesophageal echocardiography are emphasized. D 2003 Elsevier Ireland Ltd. All rights reserved. Keywords: Chronic cor pulmonale; Pacemaker; Endocarditis
Pacemaker lead infection is a rare life-threatening complication of permanent transvenous pacing [1]. The treatment seeking to prevent septic embolism is based on the total removal of the pacing apparatus. A 34-year-old man was admitted to our institution for dyspnea and hemoptysis. When he was 9 years old, this patient was implanted with a VVI pacemaker because of severe sinus bradycardia. Atrialisation was performed 5 years later. He developed infection of the pacemaker pocket (Staphhylococcus epidermidis), without lead removal 15 years ago. Transthoracic echocardiography (TTE) was considered normal. Then, the pulse generator was changed three times, even when the patient presented episodes of fever. At clinical examination, major signs of right heart failure were observed. The electrocardiogram showed sinus tachycardia, right bundle-branch block and S1Q3 pattern. TTE revealed severe right ventricular dilation, paradoxical septum (Fig. 1) and major pulmonary arterial
* Corresponding author. AP-HP, Hoˆpital Ambroise Pare´, Service de Cardiologie, 9, avenue Charles de Gaulle, 92100 Boulogne, France. Tel.: +33-149095620; fax: +33-149095344. E-mail address: [email protected] (N. Mansencal). 0167-5273/$ - see front matter D 2003 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2003.04.054
hypertension (systolic pulmonary arterial pressure = 100 mm Hg). No vegetation was observed. Left ventricular function was preserved. Ventilation-perfusion pulmonary scintigraphy revealed distal mismatch patterns. Helical CT confirmed multiple distal pulmonary embolisms. No deep venous thrombosis was found. Transesophageal echocardiography (TEE) showed a large vegetation on pacemaker lead. Three blood cultures were positive (S. epidermidis). The other causes of pulmonary hypertension were eliminated. The diagnosis of recurrent septic pulmonary embolisms was performed. No surgical pulmonary desobstruction was possible. The patient was treated with removal of the entire pacing system, antibiotics and oral anticoagulant therapy. No new pacing system was implanted. In the follow-up, neither infection nor syncope was observed. Lung or heart –lung transplantation was discussed. This case illustrates the difficulty to diagnose pacemaker lead endocarditis. Klug et al. [1] have reported that septic pulmonary embolisms were observed in 34% of patients with chronic pacemaker lead infection. To our knowledge, no case of such a severe pulmonary hypertension following lead endocarditis has been reported. Chronic cor pulmonale is a rare complication occurring in less than 1% of acute pulmonary embolism. Recurrent undiagnosed septic embolisms can explain the severity of our report. Clinical
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N. Mansencal et al. / International Journal of Cardiology 96 (2004) 119–120
Fig. 1. Parasternal long-axis and short-axis views in systole. The right ventricle is dilated, responsible for a bowing of the interventricular septum into the left ventricle. Note also a small pericardial effusion behind the left ventricle.
presentation is often torpid with S. epidermidis. The entire pacing system should be removed 15 years ago to avoid repetitive septic embolisms and their tragic pulmonary consequences. Echocardiography should be performed in patients with permanent pacemaker and atypical signs of infection. TTE combined with TEE should be performed [2]. Vilacosta et al. [3] have proved the superiority of TEE in the detection of vegetations on pacemaker leads. In patients with pacemaker, TEE is an essential tool in detecting either septic vegetations or thrombus on the leads and no pulmonary hypertension should be considered primitive without a normal TEE. This patient could not benefit from desobstructive surgery, because the usual criteria for pulmonary thromboendarterectomy was not present [4]. Simonneau et al. [5] reported that only 15% of patients with pulmonary embolism and pulmonary hypertension were suitable for surgery. The prognosis of our patient is poor. Lung or heart – lung transplantation has to be considered. It is sadly a critical
situation for a young patient with, furthermore, an uncertain indication of transvenous pacing.
References [1] Klug D, Lacroix D, Savoye C, et al. Systemic infection related to endocarditis on pacemaker leads: clinical presentation and management. Circulation 1997;95(8):2098 – 107. [2] Mugge A, Daniel WG, Frank G, Lichtlen PR. Echocardiography in infective endocarditis: reassessment of prognostic implications of vegetation size determined by the transthoracic and the transesophageal approach. J Am Coll Cardiol 1989;14(3):631 – 8. [3] Vilacosta I, Sarria C, San Roman JA, et al. Usefulness of transesophageal echocardiography for diagnosis of infected transvenous permanent pacemakers. Circulation 1994;89(6):2684 – 7. [4] Jamieson SW, Auger WR, Fedullo PF, et al. Experience and results with 150 pulmonary thromboendarterectomy operations over a 29month period. J Thorac Cardiovasc Surg 1993;106(1):116 – 26. [5] Simonneau G, Azarian R, Brenot F, Dartevelle PG, Musset D, Duroux P. Surgical management of unresolved pulmonary embolism. A personal series of 72 patients. Chest 1995;107(1 Suppl.):52S – 5S.
Letter to the Editor
Chronic cor pulmonale: a rare complication of undiagnosed pacemaker lead endocarditis Nicolas Mansencal a,*, Thomas Lavergne a, Pierre Bordachar a, Eric Abergel a, Jean-Yves Le Heuzey a, Franc¸oise Hidden b, Louis Guize a b
a Department of Cardiology, AP-HP, Hoˆpital Europe´en Georges Pompidou, Paris, France Department of Cardiology, AP-HP, Institut du Cœur, Hoˆpital la Pitie´-Salpe´trie`re, Paris, France
Received 29 December 2002; accepted 2 April 2003
Abstract Pacemaker lead infection is a rare life-threatening complication of permanent transvenous pacing. We describe the case of a young man who suffered recurrent undiagnosed septic pulmonary embolisms from pacemaker lead vegetations inducing chronic cor pulmonale with major pulmonary arterial hypertension. The potential complications of transvenous pacing and the systematic use of transesophageal echocardiography are emphasized. D 2003 Elsevier Ireland Ltd. All rights reserved. Keywords: Chronic cor pulmonale; Pacemaker; Endocarditis
Pacemaker lead infection is a rare life-threatening complication of permanent transvenous pacing [1]. The treatment seeking to prevent septic embolism is based on the total removal of the pacing apparatus. A 34-year-old man was admitted to our institution for dyspnea and hemoptysis. When he was 9 years old, this patient was implanted with a VVI pacemaker because of severe sinus bradycardia. Atrialisation was performed 5 years later. He developed infection of the pacemaker pocket (Staphhylococcus epidermidis), without lead removal 15 years ago. Transthoracic echocardiography (TTE) was considered normal. Then, the pulse generator was changed three times, even when the patient presented episodes of fever. At clinical examination, major signs of right heart failure were observed. The electrocardiogram showed sinus tachycardia, right bundle-branch block and S1Q3 pattern. TTE revealed severe right ventricular dilation, paradoxical septum (Fig. 1) and major pulmonary arterial
* Corresponding author. AP-HP, Hoˆpital Ambroise Pare´, Service de Cardiologie, 9, avenue Charles de Gaulle, 92100 Boulogne, France. Tel.: +33-149095620; fax: +33-149095344. E-mail address: [email protected] (N. Mansencal). 0167-5273/$ - see front matter D 2003 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2003.04.054
hypertension (systolic pulmonary arterial pressure = 100 mm Hg). No vegetation was observed. Left ventricular function was preserved. Ventilation-perfusion pulmonary scintigraphy revealed distal mismatch patterns. Helical CT confirmed multiple distal pulmonary embolisms. No deep venous thrombosis was found. Transesophageal echocardiography (TEE) showed a large vegetation on pacemaker lead. Three blood cultures were positive (S. epidermidis). The other causes of pulmonary hypertension were eliminated. The diagnosis of recurrent septic pulmonary embolisms was performed. No surgical pulmonary desobstruction was possible. The patient was treated with removal of the entire pacing system, antibiotics and oral anticoagulant therapy. No new pacing system was implanted. In the follow-up, neither infection nor syncope was observed. Lung or heart –lung transplantation was discussed. This case illustrates the difficulty to diagnose pacemaker lead endocarditis. Klug et al. [1] have reported that septic pulmonary embolisms were observed in 34% of patients with chronic pacemaker lead infection. To our knowledge, no case of such a severe pulmonary hypertension following lead endocarditis has been reported. Chronic cor pulmonale is a rare complication occurring in less than 1% of acute pulmonary embolism. Recurrent undiagnosed septic embolisms can explain the severity of our report. Clinical
120
N. Mansencal et al. / International Journal of Cardiology 96 (2004) 119–120
Fig. 1. Parasternal long-axis and short-axis views in systole. The right ventricle is dilated, responsible for a bowing of the interventricular septum into the left ventricle. Note also a small pericardial effusion behind the left ventricle.
presentation is often torpid with S. epidermidis. The entire pacing system should be removed 15 years ago to avoid repetitive septic embolisms and their tragic pulmonary consequences. Echocardiography should be performed in patients with permanent pacemaker and atypical signs of infection. TTE combined with TEE should be performed [2]. Vilacosta et al. [3] have proved the superiority of TEE in the detection of vegetations on pacemaker leads. In patients with pacemaker, TEE is an essential tool in detecting either septic vegetations or thrombus on the leads and no pulmonary hypertension should be considered primitive without a normal TEE. This patient could not benefit from desobstructive surgery, because the usual criteria for pulmonary thromboendarterectomy was not present [4]. Simonneau et al. [5] reported that only 15% of patients with pulmonary embolism and pulmonary hypertension were suitable for surgery. The prognosis of our patient is poor. Lung or heart – lung transplantation has to be considered. It is sadly a critical
situation for a young patient with, furthermore, an uncertain indication of transvenous pacing.
References [1] Klug D, Lacroix D, Savoye C, et al. Systemic infection related to endocarditis on pacemaker leads: clinical presentation and management. Circulation 1997;95(8):2098 – 107. [2] Mugge A, Daniel WG, Frank G, Lichtlen PR. Echocardiography in infective endocarditis: reassessment of prognostic implications of vegetation size determined by the transthoracic and the transesophageal approach. J Am Coll Cardiol 1989;14(3):631 – 8. [3] Vilacosta I, Sarria C, San Roman JA, et al. Usefulness of transesophageal echocardiography for diagnosis of infected transvenous permanent pacemakers. Circulation 1994;89(6):2684 – 7. [4] Jamieson SW, Auger WR, Fedullo PF, et al. Experience and results with 150 pulmonary thromboendarterectomy operations over a 29month period. J Thorac Cardiovasc Surg 1993;106(1):116 – 26. [5] Simonneau G, Azarian R, Brenot F, Dartevelle PG, Musset D, Duroux P. Surgical management of unresolved pulmonary embolism. A personal series of 72 patients. Chest 1995;107(1 Suppl.):52S – 5S.