case_images: PMC11732613_01
case_images: Chest X-ray (frontal view) showing two radio-opaque objects corresponding to the tips of the ventricular lead. The upper tip is projected over the left innominate vein (green arrow), and the lower tip is projected over the right ventricle (red arrow)
case_images: cureus-0017-00000077148-i01.jpg
case_images: PMC11732613_01_cureus-0017-00000077148-i01.jpg
case_images: FIG1
case_images: Imaging, chest X-ray (Figure 1), contrast-enhanced CT, and PET-CT (Figures 2-3) showed residual material in the left brachiocephalic vein and near the right ventricular wall, with associated soft tissue infection in the sternum and left pectoral region but no evidence of persistent IE on TTE or clinical grounds.
case_images: (18F)-FDG PET scan revealing pathological hypermetabolism and associated findings in cervicothoracoabdominal sections. On PET scan with (18F)-FDG imaging in sagittal cervicothoracoabdominal sections, prior to tracer injection (A), retrosternal material is observed extending into the left subclavian region (proximal end of the ICD lead), projecting over the subclavian vein and left innominate vein. Additionally, hyperdense material (right ventricular lead tip) generates artifacts at the apex of the right ventricle. One hour after (18F)-FDG tracer injection (B), intense pathological hypermetabolism is noted in the left supraclavicular region along a muscular trajectory and retrosternally, extending into the left subclavian area near the innominate vein, likely of infectious origin. This is associated with linear pathological hypermetabolism involving the manubrium and sternal body (blue arrows), extending superiorly to a pathological median suprasternal cutaneous hypermetabolism and inferiorly to hypermetabolism below the sternal notch. It further extends intrathoracically at the level of the right ventricle, adjacent to the residual material (white arrow).. FDG: fluorodeoxyglucose; ICD: implantable cardioverter defibrillator
case_images: cureus-0017-00000077148-i02.jpg
case_images: PMC11732613_01_cureus-0017-00000077148-i02.jpg
case_images: FIG2
case_images: Imaging, chest X-ray (Figure 1), contrast-enhanced CT, and PET-CT (Figures 2-3) showed residual material in the left brachiocephalic vein and near the right ventricular wall, with associated soft tissue infection in the sternum and left pectoral region but no evidence of persistent IE on TTE or clinical grounds.
case_images: (18F)-FDG PET scan showing pathological hypermetabolism in cervicothoracic sections. On PET scan (18F)-FDG imaging in a transverse cervicothoracic section, showing pathological cutaneous hypermetabolism in the median suprasternal region (blue arrow), extending into the left subclavian area over the innominate vein, which also shows pathological hypermetabolism (black arrow) (A). This hypermetabolism extends anteriorly along the K1 arc and beneath the pectoralis muscle (orange arrow) (B).. FDG: fluorodeoxyglucose
case_images: cureus-0017-00000077148-i03.jpg
case_images: PMC11732613_01_cureus-0017-00000077148-i03.jpg
case_images: FIG3
case_images: Imaging, chest X-ray (Figure 1), contrast-enhanced CT, and PET-CT (Figures 2-3) showed residual material in the left brachiocephalic vein and near the right ventricular wall, with associated soft tissue infection in the sternum and left pectoral region but no evidence of persistent IE on TTE or clinical grounds.
case_images: Echocardiogram image showing a non-dilated, non-hypertrophied left ventricle (LV), with an element at the base of the right ventricle (RV) compatible with a tip of an ICD lead (blue arrow). ICD: implantable cardioverter defibrillator
case_images: cureus-0017-00000077148-i04.jpg
case_images: PMC11732613_01_cureus-0017-00000077148-i04.jpg
case_images: FIG4
case_images: Preoperative TTE showed no vegetation or valvular involvement, with preserved cardiac function, except for a foreign body embedded at the base of the right ventricle (Figure 4); however, TEE was contraindicated.
case_images: Intraoperative photo showing the extraction using forceps, aided by adequate exposure of the left subclavian region with a retractor, from the frayed and tangled wire (blue arrow) of the ventricular lead tip that was partially retained with its sheath inside the left innominate vein through a venotomy performed with an electric scalpel
case_images: cureus-0017-00000077148-i05.jpg
case_images: PMC11732613_01_cureus-0017-00000077148-i05.jpg
case_images: FIG5
case_images: Intraoperative findings included two fistulous tracts filled with pus: the first one extending from the pocket site to a thrombosed left innominate vein containing an encased ventricular lead filled with pus, coiled and attached to the vein wall (Figure 5), which was removed after venotomy without the need for veinoplasty and was placed in a sterile container for cytobacteriological analysis (Figure 6), and the second one extending from the sternal notch to the base of the right ventricle.
case_images: Photo showing the ventricular lead tip with its sheath and tangled wires, deformed after successful extraction from the left innominate vein (A), along with surrounding infected mediastinal tissue and fragments of thrombosis (B). The specimen was placed in a sterile container for cytobacteriological and histopathological studies
case_images: cureus-0017-00000077148-i06.jpg
case_images: PMC11732613_01_cureus-0017-00000077148-i06.jpg
case_images: FIG6
case_images: Intraoperative findings included two fistulous tracts filled with pus: the first one extending from the pocket site to a thrombosed left innominate vein containing an encased ventricular lead filled with pus, coiled and attached to the vein wall (Figure 5), which was removed after venotomy without the need for veinoplasty and was placed in a sterile container for cytobacteriological analysis (Figure 6), and the second one extending from the sternal notch to the base of the right ventricle.
case_images: Intraoperative image during the second stage of surgery under cardiopulmonary bypass (CPB) with clamping, showing a right atriotomy to begin the extraction of the ventricular lead embedded in the muscular wall through the posterior pillar at the inferior wall level, following radiographic localization
case_images: cureus-0017-00000077148-i07.jpg
case_images: PMC11732613_01_cureus-0017-00000077148-i07.jpg
case_images: FIG7
case_images: The remaining ventricular lead was embedded in the right ventricular wall, firmly adherent, after right atriotomy under CPB (Figure 7) from a site showing localized infectious signs.
case_images: Intraoperative fluoroscopic image of the right ventricle showing the ventricular lead tip (blue arrow), cut and embedded in its inferior wall, serving as a guide for surgical extraction
case_images: cureus-0017-00000077148-i08.jpg
case_images: PMC11732613_01_cureus-0017-00000077148-i08.jpg
case_images: FIG8
case_images: Intraoperative fluoroscopic image centered on the right ventricle, showing the cut ventricular lead tip inside the right myocardium, with the exposure of instruments serving as landmarks for surgical extraction (A), as well as the progression of the forceps through the endocardium before grasping the lead (B)
case_images: cureus-0017-00000077148-i09.jpg
case_images: PMC11732613_01_cureus-0017-00000077148-i09.jpg
case_images: FIG9
case_images: Intraoperative photo showing the tip of the right ventricular lead (red arrow) after its extraction, following fluoroscopic localization
case_images: cureus-0017-00000077148-i10.jpg
case_images: PMC11732613_01_cureus-0017-00000077148-i10.jpg
case_images: FIG10
case_images: Postoperative day 7 chest X-ray showing the disappearance of the material at both the level of the innominate vein and the right ventricle, as well as the regression of the left pleural effusion
case_images: cureus-0017-00000077148-i11.jpg
case_images: PMC11732613_01_cureus-0017-00000077148-i11.jpg
case_images: FIG11
case_images: Postoperative recovery was uneventful, and the patient completed a four weeks course of antibiotics with a postoperative day 7 chest X-ray (Figure 11) showing the disappearance of the material at both the level of the innominate vein and the right ventricle, as well as the regression of the left pleural effusion, without complications, the infectious and inflammatory biomarkers returned to normal throughout the hospitalization, notably with the normalization of CRP levels.