Leadless Pacemaker Infective Endocarditis: Case Report and Review of the Literature

leadless pacemakers (LPM) are self-contained intra-cardiac pacing devices, affixed to the right ventricle via a transcatheter approach, designed to reduce complications associated with conventional cardiac implantable electronic devices (CIED), including device related infections (DRIs) ( 1 El-Chami M.F. Bonner M. Holbrook R. Stromberg K. Mayotte J. Molan A. et al. Leadless pacemakers reduce risk of device-related infection: Review of the potential mechanisms. Heart Rhythm. 2020; 17: 1393-1397https://doi.org/10.1016/j.hrthm.2020.03.019 Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar ). Investigational device exemption and post-approval registry studies found no DRIs in high-risk sub-groups, including those with prior CIED infection or bacteremia ( 2 El-Chami M.F. Johansen J.B. Zaidi A. Faerestrand S. Reynolds D. Garcia-Seara J. et al. Leadless pacemaker implant in patients with pre-existing infections: Results from the Micra postapproval registry. J Cardiovasc Electrophysiol. 2019; 30: 569-574https://doi.org/10.1111/jce.13851 Crossref Scopus (97) Google Scholar , 3 El-Chami M.F. Soejima K. Piccini J.P. Reynolds D. Ritter P. Okabe T. et al. Incidence and outcomes of systemic infections in patients with leadless pacemakers: Data from the Micra IDE study. Pacing Clin Electrophysiol. 2019; 42: 1105-1110https://doi.org/10.1111/pace.13752 Crossref PubMed Scopus (58) Google Scholar ). These observations contrast with the high rate of CIED involvement associated with bacteremia, particularly with Staphylococcus aureus, observed in patients with conventional CIEDs. The low risk of DRIs with LPMs is hypothesized to be secondary to the small surface area of the intra-cardiac device, device encapsulation/endothelialization, and a parylene coating which has purported antibacterial properties ( 1 El-Chami M.F. Bonner M. Holbrook R. Stromberg K. Mayotte J. Molan A. et al. Leadless pacemakers reduce risk of device-related infection: Review of the potential mechanisms. Heart Rhythm. 2020; 17: 1393-1397https://doi.org/10.1016/j.hrthm.2020.03.019 Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar ). Due to this reported low risk of DRIs, there is growing acceptance within the electrophysiology community to manage conventional CIED infections with LPM implantation at the time of conventional CIED removal (in patients with ongoing pacing requirements), even when signs of persistent infection are present ( 4 Beurskens N.E.G. Tjong F.V.Y. Dasselaar K.J. Kuijt W.J. Wilde A.A.M. Knops R.E. Leadless pacemaker implantation after explantation of infected conventional pacemaker systems: A viable solution?. Heart Rhythm. 2019; 16: 66-71https://doi.org/10.1016/j.hrthm.2018.07.006 Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar ). However, there are rare cases of LPM IE described in the literature (Table 1). Here we present a case of LPM IE and provide a summary of seven other published cases to date. Table 1Summary of case reports and characteristics of patients with leadless pacemaker infective endocarditis. # Author Year Patient age Patient sex Other risk factors for IE Time from LPM implantation to LPM IE Vegetation seen on LPM Pathogen Device extracted Outcome 1 Koay A et al. a Koay A, Khelae S, Wei KK, Muhammad Z, Mohd Ali R, Omar R. Treating an infected transcatheter pacemaker system via percutaneous extraction. HeartRhythm Case Rep. 2016;2(4):360-2. http://dx.doi.org/10.1016/j.hrcr.2016.04.006. 2016 80 F - 30 days Yes (TEE) MRSA Yes (percutaneous extraction) Survival 2 Ellison K et al. b Ellison K, Hesselson A, Ayoub K, Leung S, Gurley J. Retrieval of an infected leadless pacemaker. HeartRhythm Case Rep. 2020;6(11):863-6. http://dx.doi.org/10.1016/j.hrcr.2020.08.022. 2020 37 F Autoimmune disease (IBD) 28 days Yes (ICE) Candida albicans Yes (percutaneous extraction) Survival 3 Okada A et al. c Okada A, Shoda M, Tabata H, Kobayashi H, Shoin W, Okano T, et al. Simultaneous infection of abandoned leads and newly implanted leadless cardiac pacemaker: Why did this occur? J Cardiol Cases. 2021;23(1):35-7. http://dx.doi.org/10.1016/j.jccase.2020.09.005. 2021 80 M Retained conventional pacemaker leads 47 days No MRSA Yes (percutaneous extraction) Survival 4 Adamek KE at al. d Adamek KE, Haque N, Martinez-Parachini JR, Ayoub K, Richardson TD. Percutaneous aspiration and removal of infected leadless pacemaker vegetation. J Cardiovasc Electrophysiol. 2022;33(12):2658-62. http://dx.doi.org/10.1111/jce.15678. 2022 31 M IDU 1 year Yes (TTE) MSSA Yes (percutaneous extraction) Survival 5 Bernardes-Souza B et al. e Bernardes-Souza B, Mori S, Hingorany S, Boyle NG, Do DH. Late-Onset Infection in a Leadless Pacemaker. JACC Case Rep. 2022;4(24):101645. http://dx.doi.org/10.1016/j.jaccas.2022.09.015. 2022 89 F Hemodialysis, autoimmune disease (rheumatoid arthritis) 1.5 years Yes (TEE) MSSA No (Device retained; patient transitioned to comfort care) Death 6 Morita J et al. f Morita J, Kondo Y, Hachinohe D, Kitai T, Fujita T. Retrieval of an infectious leadless pacemaker with vegetation. J Arrhythm. 2023;39(1):71-3. http://dx.doi.org/10.1002/joa3.12814. 2023 78 M Prolonged temporary cardiac pacing 14 days* Yes (TEE) MRSA Yes (percutaneous extraction) Survival 7 Patel H et al.g 2023 66 M IDU 49 days Yes (TEE) MRSA Yes (percutaneous extraction) Survival 8 Mourad A et al. 2024 63 M - 3 years Yes (TTE) MRSA Yes (percutaneous extraction) Death *MRSA detected in blood cultures 14 days after LPM implantation, timeline from positive blood cultures to identification of LPM vegetations on TEE is unclear. LPM = leadless pacemaker, IE = infective endocarditis, TEE = transthoracic echocardiography, MRSA = methicillin-resistant Staphylococcus aureus, IBD = inflammatory bowel disease, ICE = intra-cardiac echocardiography, MSSA = methicillin-sensitive Staphylococcus aureus, IDU = injection drug use. gPatel H, Harrell S, Hreibe H, Sharkawi M, AlJaroudi W. A Rare Case of Persistent Bacteremia: Leadless Micra Pacemaker Endocarditis. Case Rep Cardiol. 2023;2023:8326020. DOI: 10.1155/2023/8326020. a Koay A, Khelae S, Wei KK, Muhammad Z, Mohd Ali R, Omar R. Treating an infected transcatheter pacemaker system via percutaneous extraction. HeartRhythm Case Rep. 2016;2(4):360-2. http://dx.doi.org/10.1016/j.hrcr.2016.04.006. b Ellison K, Hesselson A, Ayoub K, Leung S, Gurley J. Retrieval of an infected leadless pacemaker. HeartRhythm Case Rep. 2020;6(11):863-6. http://dx.doi.org/10.1016/j.hrcr.2020.08.022. c Okada A, Shoda M, Tabata H, Kobayashi H, Shoin W, Okano T, et al. Simultaneous infection of abandoned leads and newly implanted leadless cardiac pacemaker: Why did this occur? J Cardiol Cases. 2021;23(1):35-7. http://dx.doi.org/10.1016/j.jccase.2020.09.005. d Adamek KE, Haque N, Martinez-Parachini JR, Ayoub K, Richardson TD. Percutaneous aspiration and removal of infected leadless pacemaker vegetation. J Cardiovasc Electrophysiol. 2022;33(12):2658-62. http://dx.doi.org/10.1111/jce.15678. e Bernardes-Souza B, Mori S, Hingorany S, Boyle NG, Do DH. Late-Onset Infection in a Leadless Pacemaker. JACC Case Rep. 2022;4(24):101645. http://dx.doi.org/10.1016/j.jaccas.2022.09.015. f Morita J, Kondo Y, Hachinohe D, Kitai T, Fujita T. Retrieval of an infectious leadless pacemaker with vegetation. J Arrhythm. 2023;39(1):71-3. http://dx.doi.org/10.1002/joa3.12814. Open table in a new tab *MRSA detected in blood cultures 14 days after LPM implantation, timeline from positive blood cultures to identification of LPM vegetations on TEE is unclear. LPM = leadless pacemaker, IE = infective endocarditis, TEE = transthoracic echocardiography, MRSA = methicillin-resistant Staphylococcus aureus, IBD = inflammatory bowel disease, ICE = intra-cardiac echocardiography, MSSA = methicillin-sensitive Staphylococcus aureus, IDU = injection drug use. gPatel H, Harrell S, Hreibe H, Sharkawi M, AlJaroudi W. A Rare Case of Persistent Bacteremia: Leadless Micra Pacemaker Endocarditis. Case Rep Cardiol. 2023;2023:8326020. DOI: 10.1155/2023/8326020.