Pacemaker lead endocarditis – Always affecting the tricuspid valve?

M. Gercek (Bad Oeynhausen)¹, K. Friedrichs (Bad Oeynhausen)², A. Goncharov (Bad Oeynhausen)¹, F. Rudolph (Bad Oeynhausen)¹, J. Kirchner (Bad Oeynhausen)², T. K. Rudolph (Bad Oeynhausen)¹, H. Omran (Bad Oeynhausen)¹, V. Rudolph (Bad Oeynhausen)¹, M. Ivannikova (Bad Oeynhausen)^1
1Herz- und Diabeteszentrum NRW Allgemeine und Interventionelle Kardiologie/Angiologie Bad Oeynhausen, Deutschland; ²Herz- und Diabeteszentrum NRW Klinik für Kardiologie Bad Oeynhausen, Deutschland

Case Presentation: 

We present a case of a 75 years old male patient with heart failure with preserved ejection fraction, exclusion of coronary artery disease, but severe peripheral artery disease. A pacemaker was implanted due to sick sinus syndrome one year ago. Clinical course
The patient has received extensive dental restoration and 6 weeks later, he suffered from fever and dyspnoe. A CT scan showed bilateral pulmonal embolisms in a peripheral hospital. The TTE had shown vegetation on the pacemaker lead. Thus, the patient was admitted to our center for pacemaker lead endocarditis and suspected involvement of the tricuspid valve. At our center, TTE showed no sign for tricuspid valve endocarditis an no vegetations on the pacemaker lead (Figure 1).

 

However, echocardiography revealed a severe pulmonary regurgitation due to pulmonary valve endocarditis (Figure 2).

After procedural planning with computed tomography (Figure 3) patient underwent surgery with pulmonary valve replacement.

Postoperatively, patient received antibiotics on intensive care unit and anticoagulation due to bilateral pulmonary embolisms. After 6 weeks, patient was transferred to the normal ward. After adequate recovery, the patient was referred for follow up treatment in a rehabilitation center

Case Summary:
Pulmonary valve endocarditis is an extremely rare disease (2% of all patients with endocarditis). The pulmonary valve is usually neglected on echocardiography, however, in cases with unknown fever and signs of systemic infection (especially suspected pacemaker lead infection), pulmonary valve endocarditis should also be considered. A modified parasternal long and short axis views as well as a modified subcostal view can help to adequately evaluate the pulmonary valve.