Author + information
- Received December 2, 2016
- Accepted December 15, 2016
- Published online March 29, 2017.
- Erwan Salaun, MDa,b,c,∗ (, )
- Jean-Claude Deharo, MDa,d,
- Jean Paul Casalta, MDb,
- Frederic Franceschi, MD, PhDa,d,
- Sandrine Hubert, MDa,b,
- Sébastien Renard, MDa,
- Alberto Riberi, MDb,e,
- Jean Francois Avierinos, MD, PhDa and
- Gilbert Habib, MD, PhDa,b
- aDepartment of Cardiology, AP-HM, La Timone Hospital, Marseille, France
- bURMITE, Aix-Marseille Université UM 63, CNRS 7278, IRD 198, INSERM 1095, IHU, Marseille, France
- cAix-Marseille Université, CNRS, CRMBM, Marseille, France
- dAix-Marseille Université, UMR MD2, Marseille, France
- eDepartment of Cardiac Surgery, AP-HM, La Timone Hospital, Marseille, France
- ↵∗Address for correspondence:
Dr. Erwan Salaun, Service de Cardiologie, AP-HM, Hôpital Timone, 264 rue Saint Pierre, 13385, Marseille Cedex 5, France.
A 72-year-old man was referred for suspected cardiac-device-related infective-endocarditis with empirical antibiotherapy for 1 week. History reports colovesical-fistulae surgery and Escherichia coli prostatitis, respectively, 1 year and 4 weeks before, previous atrial fibrillation catheter-ablation with chronic rivaroxaban treatment and complete atrioventricular block with insertion of cardiac implantable electronic device (CIED) in 1996 (pacemaker generator change in 2007).
Transesophageal echocardiography (TEE) and computed tomography scan showed on the atrial lead a 16-mm-long oscillating mass and a second smaller mass without pulmonary embolism (Figure 1A, Online Videos 1 and 2). The patient reported fever from 38°C to 38.5°C the week before. No increase in inflammatory markers and no sign of pocket infection were observed. Blood cultures were negative. 18F-fluorodeoxyglucose positron emission tomography/computed tomography showed no uptake (Figure 1A). Antibiotherapy was continued, rivaroxaban was stopped and continuous intravenous infusion of unfractionated-heparin was started. Repeated TEE 1 week later showed a significant increase in the size of the larger mass (Figure 1B, Online Video 3). The smaller mass was no longer visible.
Although the Duke criteria are difficult to implement in suspected cardiac-device-related infective-endocarditis, it was considered possible. However mobile thrombi on device leads are frequent.
Because of the risk of CIED extraction and the doubtful diagnostic, we decided to try to snare the mass with TEE and fluoroscopy guidance to undertake histological analysis of the mass. An 8.5-F deflectable sheath (Agilis, St. Jude Medical, St. Paul, Minnesota) was advanced through a right-femoral vein access close to the atrial lead loop (Online Video 4). A triple-loop wire snare (18 to 30 mm Atrieve vascular snare, Angiotech, Vancouver, British Columbia, Canada) was directed toward the mass, which was tightened into the snare (Figure 1C, Online Video 5) and completely removed (Online Video 6).
Visual examination (Figure 1D), negative culture/polymerase chain reaction, and histological examination concluded at a noninfected thrombus. Rivaroxaban was reintroduced and antibiotherapy was stopped. Two months’ follow-up showed no sign of infection or mass recurrence.
In selected cases when there is doubt between cardiac-device-related infective-endocarditis and a mobile-lead thrombus, despite a full set of tests, snare retrieval of the mass may be a reasonable diagnostic and therapeutic option.
For supplemental videos, please see the online version of this article.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received December 2, 2016.
- Accepted December 15, 2016.
- 2017 American College of Cardiology Foundation