Infectious endocardial intracardiac defibrillator lead, infectious pericarditis, and delayed constrictive pericarditis
A 62-year-old man with history of diabetes and opium addiction for 20 years was admitted in 2007 at Sina hospital, Isfahan, Iran, for evaluation of arrhythmia. Three brothers had sustained sudden death. Coronary angiography failed to reveal any significant coronary artery disease. However, left ventricular (LV) function was severely reduced with ejection fraction of 20%. There were no intracardiac clots. The patient was placed on anti-arrhythmia drugs (Amiodarone, 400 mg, orally, three times in day) and discharged.\nOne year later, the patient was admitted with Repeated VT with severe LV dysfunction arrhythmia which did not respond to medical therapy. Generator Medtronic maximo II Vr.\nLead Medtronic 6947-65 cm3 wires.\nCoronary sinus, Right ventricle, Right atrium (RA) ICD was implanted.\nOne year following the implantation, the patient was admitted with toe infection. TTE was unremarkable, TEE showed large vegetations on the ICD lead in RA and also vegetations on the anterior leaflet of tricuspid valve. Mild (Tricuspid regurgitation) TR was present. Left ventricular ejection fraction (LVEF) was 30% []. The result of the blood culture was positive for Staphylococcus aureus which was Methicillin sensitive.\nThe decision was made to remove the device surgically throw median sternotomy in February 2011. Pericardium was normal with no fluid collection or adhesions. The patient was placed on cardiopulmonary bypass. RA was opened. Large vegetations were seen on the anterior leaflet of the tricuspid valve. These were excised and the leaflet was repaired. ICD lead was completely removed. It was fully covered by vegetations. The generator was also removed by separate incision. The cultures of excised vegetations were positive for Staphylococcus aureus, e.g., Video 1, . The patient was discharged after two weeks of treatment with good general condition.\nOne month after the surgery, the patient returned to hospital with chest pain, malaise, and no fever. CT scan showed pericardial effusion, e.g., . Left thoracotomy was done and copious amounts of purulent fluid were drained. The culture was negative. He was discharged on 7th postoperative day.\nOne month later, the patient returned with severe lower extremity edema. CT scan revealed mild pericardial effusion with few gas bubbles. No evidence of mediastinitis was found. The sternum was stable. Echocardiography showed\nEcho findings were as follows:\nModerate pulmonary arterial hypertension (PAP = 45-50 mmhg), Moderate circumferential pericardial effusion with high-density material (18 mm) at pericardium [Figures -]. He was scheduled for surgery with diagnosis of constrictive pericarditis. Thick and fibrotic pericardium was resected. Purulent pericardial fluid was drained [].\nDuring ten months follow-up after pericardiotomy, dyspnea and edema improved significantly with no evidence of life-threatening arrhythmias.