# Managing Complex Pacemaker-Associated Endocarditis With Thromboembolism in Tbilisi, Georgia: A Case Report

## TL;DR

This case report describes a 77-year-old man with pacemaker-associated infective endocarditis and septic pulmonary embolism, highlighting the challenges and successful treatment involving lead extraction and multidisciplinary care.

## Contribution

The paper presents a detailed clinical case of managing complex pacemaker-related endocarditis with thromboembolism through transvenous lead extraction and multidisciplinary collaboration.

## Key findings

- Transvenous lead extraction was successfully performed without complications in a patient with pacemaker dependence.
- Multidisciplinary management including antibiotics and anticoagulation helped mitigate embolic risks and infection.
- Follow-up imaging confirmed no residual vegetations after the procedure.

## Abstract

Cardiac implantable electronic devices (CIEDs), including permanent pacemakers, implantable cardioverter-defibrillators (ICDs), and cardiac resynchronization therapy (CRT) devices, have become crucial in managing cardiac arrhythmias and heart failure. However, despite advancements in implantation techniques and prophylactic measures, CIED-related infections, including infective endocarditis (IE), remain a significant clinical challenge. These infections contribute to considerable morbidity and mortality, often requiring prolonged hospitalization, complex interventions, and significant healthcare costs. CIED-IE is particularly concerning due to its association with systemic complications, including septic embolization, which increases the risk of adverse outcomes.

We report the case of a 77-year-old male with a history of permanent pacemaker implantation who developed pacemaker-associated infective endocarditis complicated by septic pulmonary embolism. The patient experienced recurrent febrile episodes over a year and was intermittently treated with antibiotics without a definitive diagnosis. He later presented with fever, dyspnea, and generalized fatigue, prompting further investigation.

Transesophageal echocardiography (TEE) revealed vegetation measuring 1.39 × 2.75 cm on the pacemaker lead, and pulmonary CT confirmed bilateral septic emboli, indicative of septic embolization. Two sets of blood cultures were positive for methicillin-sensitive Staphylococcus aureus (MSSA) within 12 hours. Given the high risk of complications, a multidisciplinary team, including cardiologists, infectious disease specialists, and cardiothoracic surgeons, assessed embolic risks, infection control, and pacing needs. Broad-spectrum intravenous antibiotics and anticoagulation therapy were initiated. Despite medical management, the persistent infection and embolic risk necessitated transvenous lead extraction (TLE), which was performed under general anesthesia. A temporary pacing lead was inserted due to the patient’s pacemaker dependence. The procedure was successfully performed without complications, and no residual vegetations were observed on follow-up imaging.