Leadless pacemaker tine fracture and dislodgement in infective tricuspid valve endocarditis: a case report

Device-related endocarditis is a feared complication after pacemaker implantation. The introduction of the leadless pacemaker has reduced the risk for this complication. We present for the first time in literature a case of leadless pacemaker dislocation secondary to a bioprosthetic tricuspid valve endocarditis.

A 37-year-old patient was admitted with signs of cardiogenic shock and third-degree atrioventricular block, 5 months after the implantation of a Micra MC1AVR1 leadless pacemaker. The device had been implanted at the base of the right ventricular outflow tract two weeks after a tricuspid valve replacement for the treatment of a Staphylococcus aureus native tricuspid valve endocarditis after intravenous drug abuse, complicated by a third-degree AV block. Echocardiography upon admission showed a large vegetation on the bioprosthetic tricuspid valve with dislocation of the leadless pacemaker. Interrogation of the device showed loss of atrial mechanical sensing, ventricular sensing and pacing capture. Blood cultures showed recurrence of S. aureus bacteraemia and confirmed the diagnosis of bioprosthetic valve and possible device-related endocarditis. Device dislocation and tine fracture were confirmed by cinefluoroscopy. Because of refractory septic and cardiogenic shock and ongoing drug abuse, the patient was deemed ineligible for surgery and palliative care was initiated.

Device dislodgement due to tine fracture is a rare but serious complication following leadless pacemaker implantation. Infective endocarditis with large vegetations can interact with leadless pacemakers implanted on the high septum. Clinicians should remain vigilant of endocarditis-related complications, even in the setting of leadless pacemaker devices.