Paradoxical septic emboli secondary to pacemaker endocarditis: transvenous lead extraction with distal embolization protection.

A 69-year-old woman with a history of paroxysmal atrial fibrillation and sick sinus syndrome with a dual-chamber pacemaker was admitted to our institution with Staphylococcus aureus bacteremia. She exhibited nonspecific neurologi-cal complaints, and head CT demonstrated multiple cerebral lesions consistent with septic emboli. Transesophageal echo-cardiography revealed a 3-cm vegetation on the right atrial pacemaker lead (Figure 1A, Video I in the Data Supplement). There was no evidence of aortic or mitral valve endocardi-tis; however, a patent foramen ovale with intermittent right-to-left shunting was identified (Figure 1B and 1C, Video II in the Data Supplement). Surgical removal was considered; however, the potential for hemorrhagic conversion of recent embolic strokes from high-dose heparin needed during car-diopulmonary bypass was prohibitive. Transvenous lead extraction was used and, to protect the cerebral circulation from further embolization, several Cordis Angioguard (Cor-dis, Miami, FL) devices were deployed to the cerebral circulation before lead extraction (Figure 2). Anticoagulation with 5000 U of heparin was administered for a brief period during Angioguard deployment. Both leads were successfully removed with a combination of powered and mechanical extraction sheaths. Postoperatively, the patient recovered to her baseline mental status with no imaging evidence of additional cerebral embolization. Discussion Paradoxical septic emboli associated with cardiac implant-able electronic devices, although rare, have been described previously. 1 Here, we present a case of significant cerebral septic embolization from a pacemaker lead vegetation with associated right-to-left shunting from a patent foramen ovale. With large vegetations (>4 cm), open surgical removal has been advocated by some, although there is no consensus regarding this approach. 2 Others have advocated a hybrid transvenous-surgical technique using a minimally invasive thoracotomy. 3 Surgical approaches necessitate prolonged systemic anticoagulation for cardiopulmonary bypass, which, in our patient, was felt to significantly increase the risk of cerebral hemorrhage. When vegetative material is present, distal embolization is always a concern. Typically , this is confined to the pulmonary circulation but, in the presence of right-to-left shunting, can result in systemic embolization and stroke. In an effort to minimize risk during extraction, we used distal embolization protection devices to reduce the risk of further embolization. In our patient, 3 femoral arterial sheaths were required to place the 3 distal protection devices, with a fourth device not needed, as the vertebral arteries were not codominant. Although multiple devices may be successfully placed using femoral access, the use of alternative arterial access, such as radial access, is feasible …