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Tricuspid Valve Repair inPacemaker ICD Leads and Tricuspid Valve Infective Endocarditis

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Pacemaker Leads and Triscuspid Valve Endocarditis

MS Halbreiner, A Kursbaum, JL Navia

Background: Infections of permanent pacemaker (PM) leads are  frequent, and when the infection spreads to the tricuspid valve (TV), or subvalvular apparatus, it can cause deterioration of the patient’s clinical condition.  This can lead to a required surgical intervention.  We present a successful surgical reconstruction of an active right-sided valve infection endocarditis (IE) due to a pacemaker lead infection.

History and Presentation: This is a 64 year-old male with a history of ischemic cardiomyopathy, ventricular tachycardia and ICD placement.  The patient initially presented with dyspnea, fatigue and an NYHA classification of III.  He also complained of on and off fevers for 6 months.  Blood cultures were positive for Staphylococcus hominis.  An echocardiography demonstrated multiple mobile vegetations attached to the pacemaker leads and to the anterior and septal leaflets of the tricuspid valve causing severe regurgitation (image 1).  

Procedure: A median sternotomy is made.  The ascending aorta, superior vena cava and inferior vena cava were cannulated.  Antegrade and retrograde cold blood cardioplegia solution was administered for myocardial protection.  The right atrium was then opened.  Two 4 centimeter vegetations were attached to the pacemaker leads and to the anterior and septal leaflets (image 2).  The vegetations were cleanly removed.  The pacemaker leads were carefully separated and pulled off from the RV and coronary sinus (image 3).  Autologous pericardium was then used to reconstruct the anterior and septal leaflets.  Using a 5-0 Goretex suture, the subvalavular tricuspid apparatus was repaired with attachment to the septal leaflet.  A rigid annuloplasty ring was the used to stabilize the repair. 

Postoperative echocardiogram showed preserved left and right ventricular systolic function and trivial tricuspid valve regurgitation with normal gradients (image 4).  

Conclusion: Complex surgical reconstruction of an active right-sided valve infected endocarditis due to pacemaker lead infection can yield good early and midterm results with an aggressive and extensive debridement of all infected tissue, a complete surgical extraction of the leads under direct vision and the use of biological tissue for repair.  

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