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Role of the Echocardiography Laboratory in Diagnosis and Management of Pacemaker and Implantable Cardiac Defibrillator Infection

A 68-year-old male patient presented with several weeks of fatigue, progressing to subjective fever and chills. For several days before admission he noted progressive dyspnea, and for this reason presented to the emergency department. Blood cultures grew Staphylococcus aureus. Pertinent history included an implantable cardiac defibrillator (ICD) implantation in the left chest 25 months earlier for inducible ventricular tachycardia and an ischemic cardiomyopathy. History included that of diabetes mellitus, hypertension, hypercholesterolemia, and end-stage renal disease (ESRD) for which he received chronic hemodialysis via dialysis catheter, which had been inserted 1 year earlier. Physical examination was unrevealing for source of infection. Particularly, the ICD pocket appeared unremarkable with no discomfort, fluctuance, erythema, or warmth noted. By transthoracic echocardiography (TTE) no definite abnormality was found, but electrode reverberations made imaging difficult. Subsequently, transesophageal echocardiography (TEE) revealed several mobile vegetations attached to electrodes within the right atrium (Fig. 1 and Video Fig. 1). The entire ICD system was surgically removed. Several large vegetative lesions were noted attached to the electrodes, which subsequently also grew Staphylococcus aureus. At surgery the generator pocket appeared unremarkable and cultures were sterile. The