Pacemaker lead extraction in pacemaker endocarditis with lead vegetation: usefulness of transesophageal...

While pacemaker endocarditis is rare, it is a complication that mandates removal of the permanent pacemaker system, including the electrode lead. Many modes of lead removal have been used. The choice of method is determined largely by lead type and chronicity (i.e., risk of substantial adhesions, hence, lead tip mobility). Patient selection has been based on general preoperative risk assessment. It is proposed that the presence of lead vegetation be considered in the decision-making process. Vegetation can be diagnosed by preoperative echocardiography, especially with clinical suspicion of embolism. Transesophageal echocardiography appears to be particularly sensitive. If vegetation is detected, open heart surgery should be strongly considered for lead removal as opposed to dilator sheath counter traction. The latter method risks shearing off the vegetation, which may result in septic--even massive--pulmonary embolus.