Surgical extraction of a giant intracardiac lead vegetation and epicardial pacemaker reimplantation in a pacemaker-dependent hemodialysis patient.

A 57-year old male with a dual-chamber pacemaker and 40-year history of hemodialysis and autoinflammatory disease developed a large, 35 × 35 mm intracardiac vegetation on the right ventricular pacing lead. As this mass was large enough to occlude the tricuspid valve orifice, transvenous lead extraction was deemed unsuitable. Instead, an urgent surgical extraction of the whole pacemaker system, including leads and vegetation, was conducted under cardiopulmonary bypass. In light of a high risk of recurrent blood infection, a new dual-chamber pacing system was then immediately re-established using epicardial pacing leads on the right atrium and ventricle instead of transvenous electrodes. This case of a rare, giant intracardiac lead vegetation lacked most known causal factors, except for renal failure, but a possibly immunosuppressed cardiac microenvironment due to long-term steroid therapy may have been an important influencing factor.