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Positron emission tomography in a complex case of cardiac device-related infection

Antonie J.H.H.M. van Oostrom, Maurits C.E.F. Wijffels, Willem J. van Boven, Debbie Nicastia, Lucas V.A. Boersma
DOI: http://dx.doi.org/10.1093/europace/eus108 1806 First published online: 15 May 2012

A 60-year-old man was presented with a Staphylococcus epidermidis bacteraemia of unknown origin, suspicious of cardiac device-related infection. Patient was pacemaker dependent for 30 years with multiple endovascular leads: four via the right and three via the left subclavian vein [attached to a biventricular internal cardioverter defibrillator (ICD)]. Intravenous antibiotic treatment was initiated and the ICD and five leads could be removed by using locking stylets and dilator sheaths (Cook Medical). Extraction of the remaining leads via the femoral vein was unsuccessful. Cultures of the ICD pocket and leads were negative, whereas a new blood culture was positive again for S. epidermidis. After an overnight fast, a fused 18F-labelled deoxyglucose (FDG) positron emission tomography/computerized tomography scan showed pathological FDG-uptake at the venous part of one of the remaining pacemaker leads, suggestive of infection of the lead and/or local thrombus (blue arrows in the figure) and making other sites of infection unlikely. Therefore, a sternotomy was performed with opening of the superior caval vein and the right atrium and inspection of the right ventricle (RV) to remove the pacemaker leads and large amounts of fibrous tissue. A small part of the RV lead was left in place because of tight adherence to a papillary muscle. Cultures of the removed leads and fibrotic tissue were positive for S. epidermidis. Antibiotic treatment was continued for 6 weeks with a good clinical response and normalization of the inflammatory parameters. Eventually, a definitive epicardial-lead biventricular pacemaker (Medtronic) and a completely subcutaneous-lead-ICD (Cameron Health) were implanted. Further hospital stay and 6-month follow-up were uneventful.

Conflict of interest: L.V.A.B. is a consultant and speaker for Cameron Health.

The full-length version of this report can be viewed at: http://www.escardio.org/communities/EHRA/publications/ep-case-reports/Documents/PET-CT.pdf.