Management of Cardiovascular Implantable Electronic Device Related Infective Endocarditis Complicated by Pulmonary Embolism: A Case Report

Introduction Cardiovascular implantable electronic device (CIED)-related infective endocarditis (IE) presents significant challenges in both diagnosis and management [1]. The specific sign of infection is the presence of vegetations on the leads via echocardiography. Pulmonary embolism (PE) is a known complication in patients with CIED-related IE. This case report discusses the complex management of a patient with CIED-related IE who developed PE after lead extraction. Case Presentation A 76 years old patient was admitted to the Cardiology department with a suspected CIED-related IE, with vegetations observed on CIED leads in the right atrium and tricuspid valve, confirmed by transesophageal echocardiography (TEE). Patient was referred to the heart team. To reduce the risk of embolization prior and during device removal antibiotic therapy was initiated. Follow-up TEE showed a reduction of vegetations size so surgical extraction of implantable cardioverter-defibrillator leads and cardiac resynchronization therapy (CRT) system was performed and a temporary pacemaker was connected, due to the complete atrioventricular block as a bridge to permanent CRT reimplantation. Due to persistent dyspnea following the CIED extraction pulmonary scintigraphy was performed and PE was confirmed. Treatment for PE was initiated alongside ongoing IE management. Repeated transthoracic echocardiography showed signs of pulmonary hypertension. After two months patient was readmitted to the hospital for worsening heart failure attributed to unsynchronized stimulation from leadless pacemaker and CRT was implanted. Discussion CIED-related IE is a rare complication [2]. To treat it, it is strongly recommended to initiate antibiotic therapy alongside the complete removal of the device and all implanted leads [3]. While device and lead extraction are generally considered safe, the risk of PE remains substantial in IE cases, particularly in patients with vegetation exceeding 1 cm in size [4,5]. This complication poses a significant risk of further infectious complications and can induce a rapid increase in pulmonary pressures and acutely precipitate heart failure [4,6]. Conclusions Our case describes a CIED-related IE which was complicated by PE and progression of HF. While rare, situations like these occur and necessitate expertise in complex management.