Complications of permanent dual‑chamber pacing such as late purulent pacemaker pocket infection with broken and looped atrial lead, complicated by pulmonary embolism after transvenous lead removal: a case report

We present a complication of the infected pacing system extraction by lobular pneumonia in a 73‑year‑old female patient. The pacing system involved DDD pacemaker, atrial and ventricular endocardial leads implanted 12 year beforehand. The defect of the atrial lead emerged during the pacemaker replacement 4 years ago. The diagnosis of the injury cause and its reparation were not undertaken at that time. An interruption of the atrial lead which resulted in the formation of a loop inside the cardiac chamber was found when purulant pacemaker pocket infection had been diagnosed. The patient was referred for the pacing system extraction after preoperative specific antibiotic treatment. After a long‑lasting, difficult, two‑step leads extraction procedure, pneumonia developed. An echocardiogram revealed enlargement of the right atrium and ventricle, with elevated pulmonary artery pressure up to 40 mmHg. An atypical chest X‑ray with the presence of a large pleural liquid volume led to the work‑up of hemorrhagic complications and postponed the antithrombotic therapy. With the delay of 1.5 month the pulmonary scintigraphy showed features of pulmonary embolism. The embolism was most likely caused by a vegetation mobilized from the endocardial lead and/or endocardium during the extraction maneuvers. Before the surgery, the vegetations attached to the leads or to the endocardium had not been visualized. Anticoagulant therapy with antivitamins K was successful, which resulted in the pulmonary pressure normalization. The patient has remained in a good condition for the next 3 months of follow‑up.