A 52-year-old man presented to the emergency department with externalization of a biventricular implantable cardioverter defibrillator (Figure 1). He had been admitted six months earlier with a fistula surrounding the device but left the hospital against medical advice before treatment. At admission to the emergency room his heart rate was 105 beats/min and his blood pressure was 122/96 mmHg. Cardiac auscultation revealed a systolic murmur at the apex; there were no breath sounds at the right lung base and lower limb edema was observed.

Figure 1.

Externalization of biventricular implantable cardioverter-defibrillator.

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Three sets of blood cultures were drawn before antimicrobial therapy with vancomycin was begun. Methicillin-resistant Staphylococcus aureus was subsequently isolated. Transthoracic and transesophageal echocardiography were performed and a mass was seen adhering to the lead (Figures 2 and 3). Complete device and lead removal was performed within two days. The patient received parenteral antimicrobial therapy for four weeks and a new device was implanted on the contralateral side before discharge.

Figure 2.

Transthoracic echocardiogram, apical 4-chamber view, showing thickening of the lead.

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Figure 3.

Transesophageal echocardiogram, showing a mass adhering to the lead.

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