The Multidisciplinary Approach to an Infective Endocarditis Related to the Cardiac Implantable Electronic Device (CIED-IE) in a Frail Patient: A Case Report and the Review of the Literature

Infective endocarditis (IE) can affect a native or prosthetic heart valve, the endocardial surface or an indwelling cardiac implantable electronic device (CIED).

We describe a case of CIED-IE (pacemaker or PM-related) in a frail elderly patient, discussing the role of frailty in the literature of similar cases. A comorbid and frail elderly patient was admitted to S.Andrea Hospital for fever after one week of unsuccessful antibiotic treatment. The clinical characteristics, the laboratory results and the preliminary imaging examination suggested the challenging diagnosis of CIED-IE (PM-related), on the basis of the echocardiography findings. The Heart Team (HT) examined and monitored this case with large vegetations, momentarily excluding the surgical option due the clinical characteristics of the patient and the negative blood cultures. A combined empiric antibiotic therapy was started and modified on the basis of the biomarker and ultrasound findings. The diagnosis of definite CIED infection was confirmed by a transesophageal echocardiography and a positron emission tomography (PET) with 18 fluorodeoxyglucose. Following more than 3 months of targeted antibiotic therapy, the pacemaker leads were removed via percutaneous transvenous extraction. The cultures of the leads resulted positive for Bacillus spp (possible contaminant) and Enterococcus Faecalis; the previously established empirical therapy (with imipenem and daptomycin) was considered as appropriate. The patient was finally discharged at home after four cumulative months.

The multidisciplinary Heart Team was essential in the diagnostic challenge of the disease, in the monitoring of the clinical course and in the choice of the timing of the surgery. The combined sequential medical and surgical treatment was successful in the frail patient, balancing the risks of the early extraction versus the low outcome of the chronic antibiotic therapy.