Innovative Management of Blood Culture-Negative Endocarditis With Pulmonary Septic Emboli in a Patient With a Biventricular Pacemaker and Implantable Cardioverter Defibrillator (BiV-ICD) and Psychosocial Stressors: A Case Report

Blood culture-negative endocarditis (BCNE) poses significant diagnostic and therapeutic challenges and is associated with notable morbidity and mortality. When presented concurrently with other comorbidities, these challenges and the chances of morbidity and mortality significantly increase. This case presents right-sided BCNE accompanied by pulmonary cavitary lesions in a patient with a history of supraventricular tachycardias (SVT), a biventricular pacemaker and implantable cardioverter-defibrillator (BiV-ICD), alcohol use, and anticoagulant noncompliance. The patient missed follow-up appointments for six months after the death of his wife, leading to increased alcohol use and noncompliance with medications. During this period, his home monitoring device was offline. Once reconnected, it detected several episodes of SVT and ventricular tachycardia (VT), prompting a wellness check. He presented to the cardiology clinic with shortness of breath and a cough producing brown-tinged sputum. Evaluation revealed cavitary lesions in the lingula and left lower lobe, a vegetation on his tricuspid valve, and vegetations on his endocardial leads, despite negative blood cultures. Tuberculosis testing was negative, while sputum cultures were positive for Haemophilus influenzae. After ruling out other possible infectious causes of the cavitary lesions, septic emboli were suspected as the cause. Broad-spectrum antibiotics were begun and surgical intervention was done to replace the tricuspid valve and remove the endocardial leads. This procedure was complicated by fibrosis of the leads at the coronary sinus, necessitating their cutting at the superior vena cava and leaving them inside the patient until laser therapy could be performed for their removal. The patient's history of bradycardia and SVTs required the ongoing use of a pacemaker. Inventory discrepancy during the placement of the new pacemaker epicardial leads lead to complications warranting an alternative approach to lead implantation. A traditionally used epicardial lead was placed on the right ventricle for pacing, and an innovative technique was employed to place an endocardial lead on the right atrium epicardium for sensing. This case underscores the importance of thorough evaluation and collaborative management strategies to optimize outcomes for patients with concomitant cardiac and pulmonary pathologies, particularly in the context of underlying psychosocial stressors. Additionally, it demonstrates solutions to challenges that can arise during surgery and presents an alternative lead placement technique for physicians who have only one epicardial lead available after removing infected endocardial leads. This is illustrated by the innovative use of an endocardial lead as an epicardial sensing lead.