SEPTICEMIA AND ENDOCARDITIS RELATED TO TR ANSVENOUS PACING LEADS AND PERMANENT PACEMAKERS - SURGICAL INDICATIONS AND RESULTS

Endocarditis of transvenous pacing leads is a rare condition. The auth ors review a series of 15 patients who developed bacteriologically pro ven septicaemia and/or endocarditis related to transvenous pacing lead s, operated between 1988 and 1993. The interval between the last manip ulation of the pacemaker and the onset of endocarditis was about 6 mon ths. Six patients had had haematoma and/or infection of the pacemaker site. Endocarditis presented with chronic pyrexia (14 cases) associate d with septicaemia (6 cases) and chronic local suppuration (1 case). T he interval between the beginning of the pyrexia and the diagnosis was 3.4 months. Echocardiography showed a mass attached to the pacing lea d in 8 cases and tricuspid valve vegetations in 4 cases. Blood culture s were positive in 13 patients and local wound swabs identified the or ganism in 1 patient. The commonest causal agent was the staphylococcus (epidermis in 7 cases, aureus in 4 cases). Appropriate antibiotic the rapy was only effective in 1 case. The surgical indication in 13 cases was persistence of infection associated with pulmonary embolism (3) o r tricuspid regurgitation (2). Complete ablation of the prosthetic mat erial was performed by a peripheral vascular approach (2 cases), by a right atrial approach (1 case) and under cardiopulmonary bypass in 12 cases. The peroperative findings were of tricuspid valve vegetations ( 4 cases), thrombi on the pacing lead (7 cases) or in the right heart c hambers (2 cases) or pulmonary artery (2 cases). The associated proced ures performed under cardiopulmonary bypass were tricuspid valve repai r (2 cases) and pulmonary thrombectomy (2 cases). Temporary and perman ent epicardial leads were implanted in 10 patients. Two patients with severe cardiomyopathy died in low output conditions on the 3rd postope rative day. Two other patients died, one after 2 months of septicaemic shock due to pyocyanic pneumonia, the other after 4 months, due to co mplications of a cerebrovascular accident. After an average follow-up period of 17 months (range 1 to 48 months) the other 11 patients are a live and free of recurrence of infection. The authors conclude that en docarditis related to transvenous pacing leads is a serious complicati on, often escaping diagnosis and essentially due to repeated manipulat ion of the pacemaker and/or the pacing leads.