Dramatic improvement of left ventricular function after swit
Eight years ago, a DDD pacemaker was implanted in an elderly man due to complete atrioventricular (AV) block. The pacing sites were the appendage of the right atrium and the apex of the right ventricle subsequently he suffered PICM with an LV ejection fraction of 37% and obvious dyssynchrony. He had chronic heart failure of NYHA II. Suddenly, the patient developed fever and complained of difficulty eating. Transthoracic echocardiography showed a vegetation (11 × 12 mm2) at the pacemaker leads, and this vegetation was also attached at the tricuspid valve. Laboratory examination showed elevated white blood cell count and C reactive protein levels. He was diagnosed with PAIE, although the peripheral blood cultures showed no bacteria. After antibiotic therapy, laboratory examination showed decreasing inflammation parameters, but the size of the vegetation remained stable.

According to the current guideline for pacemaker infection, it was decided to remove the whole pacemaker system, including the two leads. Since implantation of new transvenous leads seemed undesirable because of ongoing active endocarditis, it was decided to implant epicardial leads on the left atrium and left ventricle via a left mini thoracotomy. Because the patient had complete AV block without any spontaneous R wave, a new DDD pacemaker system was implanted first. The atrial lead was implanted on the appendage of the left atrium, and the ventricular lead was implanted onto the lateral wall of the left ventricle near the first obtuse marginal branch. The old infected pacemaker system was then explanted by percutaneous extraction.

After the operation, the patient recovered rapidly. Of note, postoperative transthoracic echocardiography showed dramatically improved LV function, with EF of 56%. Moreover, dyssynchrony disappeared. On the other hand, the vegetation at the tricuspid valve remained unchanged. He was transferred to a territorial hospital for further therapy with antibiotics on the seventh postoperative day. Now, 3 years after surgery, the patient is doing very well without any sign of heart failure.

Source: Journal of Surgical Case Reports, Volume 2019, Issue 5, May 2019, rjz155

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