Endocarditis Associated with Pacemaker Leads and Central Venous Catheters

Masses adherent to intracardiac catheters and leads are common even in the absence of IE. Thus, the diagnosis of IE in this clinical setting requires clinical correlation such as the use of the Duke criteria. Vegetations associated with pacemaker leads can occur either in the atrium or ventricle, ranging in size from less than 5 mm to over 20 mm [56]. Echo evidence of vegetation is present in the majority of patients with pacemaker lead IE. In addition to the typical shaggy, mobile, soft echodensity characteristic of

A

Figure 7.17. A large pseudoaneurysm at the posterior aortic root on transesophageal echocardiography (A).This serves as a fistula connecting the left ventricle with the aorta. Color flow imaging shows flow from the pseudoaneurysm into the left ventricular outflow tract during diastole (B). This is the same patient as in Figure 11.

Figure 7.17. A large pseudoaneurysm at the posterior aortic root on transesophageal echocardiography (A).This serves as a fistula connecting the left ventricle with the aorta. Color flow imaging shows flow from the pseudoaneurysm into the left ventricular outflow tract during diastole (B). This is the same patient as in Figure 11.

vegetations, infected pacemaker leads can have a sleeve-like appearance on the sheath [57]. In rare cases of pacemaker lead IE, this sleeve-like appearance on the pacemaker lead may be the only abnormality with no echo evidence of mobile masses. Vegetations attached to the tri-cuspid valve are found in the minority of patients [56]. In contrast to IE affecting native right-sided valves, pacemaker-lead-related endocarditis is much more likely to be detected using TEE. Overall, TEE is more sensitive for detecting pacemaker-related vegetations than TTE [57]. Therefore if pacemaker lead endo carditis is suspected but not detected by TTE, TEE should be performed.

Endocarditis can also arise in the setting of indwelling central venous catheters. As is the case for pacemaker-lead-associated IE, TEE is more sensitive for the detection of vegetations in the setting of indwelling catheters than TTE [57].

Summary

1. TEE is more sensitive than TTE for the diagnosis of pacemaker-lead-associated IE.

2. Both mobile masses and a sleeve-like echodensity on the intracardiac leads are echo findings of pacemaker associated vegetations.

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