A serendipitous identification of a lead extraction complication

A 57-year-old male with a dual chamber pacemaker and symptomatic, persistent atrial fibrillation (AF) accompanying a febrile illness presented for elective transesophageal echocardiography (TEE)-guided cardioversion. The patient was found to have a large 2.5 cm × 2.3 cm, mobile mass attached to the right atrial lead. Following device and lead extraction, he developed progressive shortness of breath which was attributed to his underlying arrhythmia. One month later, AF ablation was pursued and preablation TEE revealed a dilated main pulmonary artery with a 1.8 cm × 1.6 cm mass in the distal left pulmonary artery, which was corroborated by a 1.4 cm × 2.5 cm filling defect in the descending left pulmonary artery on magnetic resonance angiography (MRA). To our knowledge, this is the first case report to document the distal migration of vegetation material into the pulmonary artery with serial TEE and highlights the risk of pulmonary embolism (PE) in patients with large endocardial lead vegetations undergoing transvenous lead extraction.