A broken lead to an open heart: implantable cardioverter def
The patient is a 40-year-old male with a medical history significant for non-ischemic cardiomyopathy with severely reduced left ventricular ejection fraction of 20%-25% requiring a biventricular implantable cardioverter-defibrillator (ICD) in 2017 who presented to the hospital for replacement of an ICD lead after the device alerted for a fractured coil. Chest x-ray in posteroanterior view showed the ICD in situ with a right lung base opacity/density which may represent a mass. The patient underwent a transesophageal echocardiogram (TEE) prior to the lead extraction which demonstrated extensive mobile masses adhering to the right atrium and right ventricle, each measuring approximately 2 cm in size and concerning for thrombi or vegetations. The procedure was aborted, and the patient was referred to cardiothoracic surgery for an open extraction and evaluation of the lead and masses. At that time, the patient was afebrile with a temperature of 36.4 degrees Celsius, a heart rate of 79 beats per minute, and blood pressure of 165/94 mmHg; the rest of the physical exam was unremarkable, including cardiac exam which did not reveal any murmurs or gallops. Broad spectrum antibiotics Vancomycin and Piperacillin-Tazobactam were started, and blood cultures were obtained. They subsequently grew Staphylococcus epidermidis in only one bottle. This was attributed to skin contamination and the antibiotics were discontinued.

The patient subsequently had right atrial exploration by the cardiothoracic surgery team with the removal of the ICD leads and generator, which revealed soft vegetative tissue overlying the wires. Cultures from the cardiac tissue were obtained and were negative for any bacterial growth. The pathology of the vegetative tissue was found to be sterile fibrinous vegetation with prominent calcification. The patient was extubated after the procedure and was discharged home a few days later with a wearable cardioverter defibrillator.