2009 Southern Regional Meeting Abstracts

Case Report: About 0.6 to 3.2 % of patients with a cardiac device develop severe infection and endocarditis which carries a mortality rate close to 30 % . It is generally accepted that IV antibiotic therapy and system removal have better outcomes than antibiotic treatment alone . Depite this, some cases have persistent thrombus or vegetation after device explantation . There are no well defined management criteria for these cases.
We present a case of a 46 year old male with history of nonischemic cardiomyopathy who had implantation of a biventricular pacing defibrillator. Two years later the patient was found to have LV lead dislodgement and subsequently underwent unsuccessful revision of the lead. One month after the attempted revision an epicardial lead was placed. Eight months later he presented with fever and constitutional symptoms. Blood cultures were positive for coagulase-negative Staphylococcus. Echocardiography demonstrated a 1.9 cm mobile mass near the endocardial leads as they entered the right atrium. The endocardial leads and generator were explanted. The patient received six weeks of intravenous Vancomycin. Several weeks after completion of antibiotic therapy blood cultures were positive again. A new Echocardiogram revealed a mobile thrombus at the SVC/RA junction. Subsequently Catheter directed thrombolysis was performed by infusion of Alteplase. Echocardiography performed immediately after the procedure and 1 month later revealed no vegetation. A new course of intravenous antibiotic was given. Repeated blood cultures were negative. After 3 months patient underwent successful implantation of a new biventricular defibrillation system.
Based on our case and literature review we suggest that local thrombolysis is a good alternative to surgical removal of persistent septic thrombi in cardiac device infection. The incidence of septic pulmonary emboli after thrombolysis is reported to be low in the few cases and studies found in our literature search.