Paradoxical Septic Emboli Secondary to Pacemaker Endocarditis Transvenous Lead Extraction With Distal Embolization Protection

A 69-year-old woman with a history of paroxysmal atrial fibrillation and sick sinus syndrome with a dual-chamber pacemaker was admitted to our institution with Staphylococcus aureus bacteremia. She exhibited nonspecific neurological complaints, and head CT demonstrated multiple cerebral lesions consistent with septic emboli. Transesophageal echocardiography revealed a 3-cm vegetation on the right atrial pacemaker lead (Figure 1A, Video I in the Data Supplement). There was no evidence of aortic or mitral valve endocarditis; however, a patent foramen ovale with intermittent right-to-left shunting was identified (Figure 1B and 1C, Video II in the Data Supplement). Surgical removal was considered; however, the potential for hemorrhagic conversion of recent embolic strokes from high-dose heparin needed during cardiopulmonary bypass was prohibitive. Transvenous lead extraction was used and, to protect …