Candida glabrata Infection on Retained Implantable Cardioverter Defibrillator Lead in Heart Transplant Patient Requiring Redo Upper Mini-Sternotomy Approach

We present the first documented case of a Candida glabrata infection on the retained lead of a cardiovascular implantable electronic device (CIED) in an immunosuppressed heart transplant recipient. This is the first documented case of a redo upper mini-sternotomy approach for a lead removal and innominate vein reconstruction with bovine patch. The patient is a 55 year-old male with non-ischemic cardiomyopathy with biventricular implantable cardioverter defibrillator (ICD) placement who underwent orthotropic heart transplant. ICD leads were divided at that time. A contralateral pacemaker was inserted postoperatively for complete heart block. The patient presented with four weeks of fever and erythema at the site of previous ICD placement. Transesophageal echo revealed echogenic structures measuring 1.8 cm and 1.1 cm attached to the pacer wire near the junction of the right atrium and inferior vena cava. Pacemaker leads were removed successfully. However, one of the three ICD leads fractured during extraction, leaving a residual coil. Culture of the extracted leads grew C. glabrata. A multi-disciplinary team including cardiothoracic surgery, infectious diseases, and cardiology determined that the most reliable way to eradicate infection would be to combine surgical management with aggressive medical management. Given multiple prior sternotomies, risk of re-entry into the thoracic cavity posed additional risks. An alternative surgical approach was performed to minimize risk.