HISTORY, CURRENT DISEASE AND PHYSICAL EXAMINATION
The case in question focuses on a 72-year-old male admitted to the coronary care unit (CCU) for arrhythmic storm in November 2016. The personal history of this patient is: Independent for basic activities of daily living (ABVD). Smoker. Arterial hypertension (AHT), dyslipidaemia, type 2 diabetes mellitus on treatment with oral antidiabetics (OAD). Stage 3A chronic kidney disease (CKD). Severe chronic obstructive pulmonary disease (COPD). Bladder neoplasia in 2011 treated with surgery (cystoprostatectomy + Bricker ureteroileostomy) and later QT. Cardiological history: chronic ischaemic heart disease (acute myocardial infarction [AMI] in 1999) stable, with follow-up by his primary care physician. As previously mentioned, the patient was admitted in an arrhythmic storm. To stop the arrhythmic problem in the acute phase, the patient required five cardioversions and continuous venous perfusion of procainamide. Due to persistent non-sustained ventricular tachycardia (NSVT) of similar morphology to that described above, the patient was overstimulated by femoral electrocatheter, and the arrhythmogenic activity was resolved.
During his admission, coronary angiography was performed which showed diffuse ischaemic heart disease, with 3-vessel disease, without acute lesions and cardiac surgery was ruled out, given the patient's high surgical risk. The patient was referred for electrophysiological study (EPS) and ablation of ventricular tachycardia (VT) which, as a complication, presented complete atrioventricular (AV) block that persisted after 1 week of EPS, it was therefore finally decided to implant a bicameral implantable cardioverter defibrillator (ICD) (because he had ischaemic heart disease without acute lesions that could explain the arrhythmic storm, with severe ventricular dysfunction - EF4C Simpson 30% - and a prognosis of more than 12 months) and he was discharged with the following treatment: adiro 100 mg (1 tablet daily), bisoprolol 5 mg (1 tablet in the morning), atorvastatin 40 mg (1 tablet in the evening), amiodarone 200 mg (every 24 hours at lunch), inhaled indacaterol/glycopyrronium (every 24 hours), budesonide 200 mcg (every 12 hours), hydroferol ampoule (drinkable every 10 days). The patient remained asymptomatic for angina and ventricular arrhythmias for 8 months, until July 2017 when he was admitted to internal medicine for febrile syndrome under study.

COMPLEMENTARY TESTS
ANALYTICS on admission (23 July 2017): creatinine 1.95 mg/dl (33.9 ml/mi/1.73 m2), urea 52 mg/dl, sodium 137 mEq/l, potassium 4.3 mEq/l, CRP 37.2 mg/dl, INR 1.02, Hb 10.7 g/dl, Hto 31.2%, leukocytes 21900 (PMN 92%), platelets 207000.
HEMOCULTURES: 23/07: positive for Staphylococcus aureus oxacillin sensitive. 06/08: negative. 09/08: negative. 11/08: Staphylococcus epidermidis grows in a bottle (considered contamination). 14/08: negative. 16/08: negative. 21/08: negative. 24/08: negative. 28/08: negative.

THORAX RADIOGRAPHY: slightly rotated plaque with cardiothoracic index (CTI) at the limit of normality, slight signs of vascular redistribution. Right atrium (RA) and right ventricle (RV) electrodes in normal position, with no signs of fracture. PET-CT scan: Focal uptake in the path of the LAD lead at the level of the left subclavian artery suspected to correspond to the infectious process causing the bacteraemia and fever, with another smaller and milder uptake observed in the posterosuperior face of the LAD at the exit of the lead, probably related to the same aetiology. Discrete bilateral pleural effusion. Post radical cystoprostatectomy changes with Bricker shunt. No other hypermetabolic locations in the rest of the study.
TEE: non-dilated left ventricle (LV), with severe depression of myocardial function and akinesia of all anterior and lateral segments. RV with LAD lead, in which at the level of the tricuspid valve there is a sessile, beating image, compatible with vegetation dependent on the device lead, measuring 3 x 5 mm.

CLINICAL EVOLUTION
The patient remained asymptomatic for 8 months until July 2017, when he was admitted to internal medicine for febrile syndrome under study. Blood cultures (2 x 2 serial cultures) showed Staphylococcus aureus. A transesophageal echocardiogram was requested, which showed vegetation on the device. A PET-CT scan was requested, which showed infection of the ICD lead. Initially, daptomycin had been prescribed, which was changed to cloxacillin with the antibiogram results. After confirming infection of the ICD catheter, daptomycin adjusted to glomerular filtration rate and rifampicin were reintroduced. Gentamicin was not added due to deterioration of renal function. He was transferred to cardiac surgery at the reference centre for explant of the device, and extraction with energy sources was performed. Subsequently, she was readmitted to the OCU, remaining with an escape rate of 36-38 bpm with good tolerance. Antibiotic therapy with cloxacillin was maintained during admission. The patient had episodes of NSVT and, despite the bradycardia, amiodarone was reintroduced. The patient tolerated sitting and ambulation with no signs of low cardiac output. After negative culture serology and a control echocardiogram with no evidence of vegetation, it was decided to implant a new device. The possibility of an epicardial approach was discussed, but finally, transvenous ICD-DDD implantation was performed. After discharge, the patient was monitored by the infectious disease service of our centre and has remained clinically stable to date.

DIAGNOSIS
Endocarditis due to methicillin-sensitive S. aureus on native tricuspid valve associated with device. Complete AV block post-ablation. History of arrhythmic storm that led to ICD implantation. Chronic ischaemic heart disease. Mild ventricular dysfunction. Moderate pulmonary hypertension. Severe COPD. Stage 3A chronic kidney disease. Functional monorenal. Cystoprostatectomy and Bricker ureteroileostomy for bladder neoplasia in 2011 and prostatic adenocarcinoma. Arterial hypertension. Diabetes mellitus. Dyslipemia
