Thouraya FILALI
Wafa Fehri
Mohamed Ben Moussa
Sami Chriaa
Nadia Barakett
Mehdi Gommidh
Dhaker Lahidheb
Othmen Salah
Nadhem Hajlaoui
Imène Saaidi
Abdedayem Haggui
Zahreddine Smiri
Habib Haouala


Infective endocarditis is an uncommon but potentially lethal complication of permanent cardiac pacing. Infection is mainly caused by local contamination during the implantation procedure. The most frequently detected causative microorganisms were staphylococci. The clinical presentation is often atypical causing prolonged diagnostic delay. Bacteriological data and visualisation of neostructures consistent with vegetations on transoesophageal echocardiography, strongly suggest pacemaker lead infection. Management is based on a combined approach using both prolonged antibiotic treatment and early complete device explantation.
Percutaneous techniques are currently the method of choice for lead extraction but it is not without possible complications. Antibiotic prophylaxis in order to reduce infection risk related to pacemaker implantation is widely recommended.


endocarditis, pacemaker, staphylococcus species, echocardiography



  1. Del Rio A, Anguera I, Miro J et al. Surgical treatment of pacemaker and defibrillator lead endocarditis. Chest 2003; 124: 1451-1459.
  2. Victor F, De Place C, Camus C et al. Pacemaker lead infection: echocardiographic features, management and outcome. Heart 1999; 81: 82-87.
  3. Uslan D, Sohail M, Friedman P et al. Frequency of permanent pacemaker or implantable cardioverter-defibrillator infection in patients with gram-negative bacteremia. Clinical Infectious Diseases 2006; 43: 731-736.
  4. Klug D, Balde M, Pavin D et al. Risk factors related to infections of implanted pacemakers and cardioverter-defibrillators. Circulation 2007; 116: 1349-1355.
  5. Sohail RM, Uslan DZ, Khan AH et al. Management and outcome of permanent pacemaker and implantable cardioverterdefibrillator infections. J Am Coll Cardiol 2007; 49: 1851-1859.
  6. Meune C, Arnal C, Hermand C et al. Les endocardites infectieuses sur sondes de pacemaker. Ann Med Interne 2000; 151: 456-464.
  7. Dy Chua J, Wilkoff B, Lee I et al. Diagnosis and management of infections involving implantable electrophysiologic cardiac devices. Ann Intern Med 2000; 133: 604-608.
  8. Klug D, Wallet F, Kacet S et al. Detailed bacteriologic tests to identify the origin of transvenous pacing system infections indicate a high prevalence of multiple organisms. Am Heart J 2005; 149: 322-328.
  9. Klug D, Wallet F, Lacroix D et al. Local symptoms at the site of pacemaker implantation indicate latent systemic infection. Heart 2004; 90: 882-886.
  10. Da Costa A, Kirkorian G, Isaaz K, Touboul P. Infections secondaires à l'implantation d'un pacemaker. Rev Med Interne 2000; 21: 256-265.
  11. Uslan DZ, Sohail RM, Sauver J et al. Permanent pacemaker and implantable cardioverter-defibrillator infections. Arch Intern Med 2007; 167: 669-675.
  12. Greenspon AJ, Rhim ES, Mark G, Desimone J, Ho RT. Leadassociated endocarditis : the important role of methicillin-resistant Staphylococcus aureus. Pacing Clin Electrophysiol. 2008; 31(5): 548-53.
  13. Baddour L, Bettmann M, Bolger A et al. AHA scientific statement: Nonvalvular cardiovascular device-related infections. Circulation 2003; 108: 2015-2031.
  14. Klug D, Wallet F, Kacet S, Courcol R. Involvement of adherence and adhesion staphylococcus epidermidis genes in pacemaker lead-associated infections. J Clin Microbiol 2003; 41: 3348-3350.
  15. Galdbart J, Allignet J, Tung S et al. Screening for staphylococcus epidermidis markers discriminating between skin-flora strains and those responsible for infections of joint prostheses. J Infect Dis 2000; 182: 351-355
  16. Erdinler I, Okmen E, Zor U et al. Pacemaker related endocarditis. Jpn Heart J 2002; 43: 475-485.
  17. Chauhan A, Grace AA, Newell SA et al. Early complications after dual chamber versus single chamber pacemaker implantation. Pacing Clin Electrophysiol 1994; 17: 2012-2015.
  18. Aggarwal RK, Connelly DT, Ray SG et al. Early complications of permanent pacemaker implantation: no difference between dual and single chamber systems. Br Heart J 1995; 73: 571-575
  19. Sohail RM, Uslan DZ, Khan AH et al. Risk factor analysis of permanent pacemaker infection. Clinical Infectious diseases 2007; 45: 166-173.
  20. Leprince P, Nataf P, Cacoub P et al. Septicémies et endocardites sur sondes endocavitaires de stimulateur cardiaque; indications chirurgicales et résultats. Arch Mal Coeur 1995; 88: 241-246.
  21. Sohail RM, Uslan DZ, Khan AH et al. Infective endocarditis complicating permanent pacemaker and implantable cardioverterdefibrillator infection. Mayo Clin Proc 2008; 83: 46-53.
  22. Anguera I, Del Rio A, Miro JM et al. Staphylococcus lugdunensis infective endocarditis: description of 10 cases and analysis of native valve, prosthetic valve and pacemaker lead endocarditis clinical profiles. Heart 2005; 91: 1-10.
  23. Cajoto IV, Framil MR, Collado A et al. Permanent transvenous pacemaker infections: an analysis of 59 cases. Europ J Internal Med 2007; 18: 484-488.
  24. Nucifora G, Badano L, Hysko F et al.Pulmonary embolism and fever : when should right-sided infective endocarditis be considered ? Circulation 2007; 115: 173-176.
  25. Dumont E, Camus C, Victor F et al. Suspected pacemaker or defibrillator transvenous lead infection: prospective assessment of a TEE-guided therapeutic strategy. European Heart J 2003; 24: 1779-1787.
  26. Klug D, Lacrois D, Savoye C et al. Systemic infection related to endocarditis on pacemaker leads clinical presentation and management. Circulation 1997; 95: 2098-2107.
  27. Dalal A, Asirvatham SJ, Chandrasekaran K et al. intracardiac echocardiography in the detection of pacemaker lead endocarditis. J Am Soc Echocardiogr 2002; 15: 1027-1028.
  28. Bracke FA, Meijer A, Van Gelder LM. Pacemaker lead complications: when is extraction appropriate and what can we learn from published data? Heart 2001; 85: 254-259.
  29. Field ME, Jones S, Epstein LM. How to select patients for lead extraction. Heart Rhythm 2007; 4: 978-985.
  30. Chamis AL, Peterson GE, Cabell CH et al. staphylococcus aureus bacteraemia in patients with permanent pacemakers or implantable cardioverter-defibrillators. Circulation 2001; 104: 1029-1033.
  31. Kennergren C, Bucknall CA, Butter C et al. Laser-assisted lead extraction: the European experience. Europace 2007; 9: 651-656.
  32. Bracke FA, Meijer A, Van Gelder LM. Lead extraction for device related infections: a single-centre experience. Europace 2004; 6: 243-247.
  33. Bracke FA. The lead extractor's toolbox: a review of current endovascular pacemaker and ICD lead extraction techniques. Ind Pac Electrophysiol J 2003; 3: 101-108.
  34. Centella T, Oliva E, Garcia-Andrade I et al. Percutaneous extraction of pacemaker and defibrillator leads. Rev Esp Cardiol 2007; 60: 607-615.
  35. Jones S, Eckart R, Albert C et al. Large, single-center, singleoperator experience with transvenous lead extraction: outcomes and changing indications. Heart Rhythm 2008; 5: 520-525.
  36. Rizzello V, Russo A, Casella M and Biddau R. Residual fibrous tissue floating in the right atrium after percutaneous pacemaker lead extraction: an unusual complication early detected by intracardiac echocardiography. International J of Cardiology 2008; 127: 67-68
  37. Novaro GM, Saliba W, Jaber WA. Fate of intracardiac lead vegetations after percutaneous lead extraction. Circulation 2002; 106: 46.
  38. Meir-Ewert H, Gray ME, John RM. Endocardial pacemaker or defibrillator leads with infected vegetations: a single-center experience and consequences of transvenous extraction. Am Heart J 2003; 146: 339-344.
  39. Nguyen KT, Neese P, Kessler DJ. Successful laser-assisted extraction of four pacemaker leads associated with large vegetations. Pacing Clin Electrophysiol 2000; 23: 1260-1262
  40. Rastan AJ, Doll N, Walther T et al. Pacemaker dependent patients with device infection- a modified approach. Europ J Cardiothoracic Surgery 2005; 27: 1116-1118.
  41. Zei PC, Eckart RE, Epstein LM. Modified temporary cardiac pacing using transvenous active fixation leads and external resterilized pulse generators. J Am Coll Cardiol 2006; 47: 1487-1489
  42. Harcombe AA, Newell SA, Ludman PF et al. Late complications following permanent pacemaker implantation or elective unit replacement. Heart 1998; 80: 240-244.
  43. Da Costa A, Kirkorian G, Cucherat M et al. Antibiotic prophylaxis for permanent pacemaker implantation: a metaanalysis. Circulation 1998; 97: 1796-1801.