THE CLINICAL CASE

A 76 year-old male presented to our hospital with a history of fever for the past three months. On this day, he had a fever of 101°F and pallor, but there were no findings on his physical examination of infective endocarditis (IE).

History of present illness:• 5 years prior: The patient had a VVI pacemaker

implantation on his right side by a subclavian venous puncture technique for a complete heart block. Within a week of implantation, he had a pacing threshold-related problem with the lead; a new lead was inserted, and the previous lead was capped.

• 8 months prior: The patient presented with a loss of pacemaker capture. On evaluation, a lead fracture was diagnosed and a new lead was inserted. Attempting to insert a third lead on the right side failed. As such, a new lead was implanted and connected to the same pacemaker on the left side. No attempt was made to remove the right-sided leads. He was left with three leads in situ. (Fig. 1)

• 4 months prior: The patient had a high-grade fever (104°F) and severe chills. He consulted several physicians and received empiric treatment for malaria and for a suspected urinary tract infection. He was hospitalized and started on intravenous (IV) ceftriaxone and amikacin for a week and showed some improvement. After a change to oral antibiotics he had a relapse of fever. A computed tomography (CT) scan showed a complete occlusion of the left subclavian vein.

DIAGNOSIS AND TREATMENT

A laboratory evaluation showed a very high erythrocyte sedimentation rate (ESR) of 110 mm/hour, consistent with infectious endocarditis (IE); a transthoracic echocardiography showed mobile vegetations attached to the base of tricuspid valve leaflet and to the pacemaker lead. He was treated with IV antibiotics for IE, the fever resolved, and he remained afebrile.

The patient was taken to the cardiac catheterization laboratory, where the whole system (three leads and pacemaker) were removed after a temporary pacemaker insertion. With sustained traction, all of the leads could be explanted completely and a VVI pacemaker was inserted through the right side. The pacemaker insertion was difficult because of fibrosis and anatomical distortion

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Treating Device-Associated Endocarditis and ChylothoraxProfessor Upendra Kaul, MD is currently Executive Director and Dean of Academics and Clinical Research at Fortis Health Care and Executive Director Cardiology at Fortis Hospital, Vasant Kunj, New Delhi.

Fig. 1

of the venous system. (Fig. 2) Serial dilatation using 5 to 8 French dilators passed over an extra support guide wire was required to insert the venous sheath into the subclavian vein. Through this sheath a screw-in bipolar lead was positioned in the right ventricle and a VVI pacemaker was connected to it.

A NEW COMPLICATION

A chest radiograph taken an hour after implantation showed evidence of pleural collection on the right side. However, the patient remained hemodynamically stable and did not have a drop in his hemoglobin level.

We also suspected hemothorax, and decided to proceed with a pleural tap and intercostal drainage, if needed. A wide-bore needle was inserted into the pleural cavity; we were surprised that instead of blood, we withdrew about 1.2 liters of a milky fluid resembling chyle. An analysis of the chylous fluid showed a triglyceride content of 95 mg/dL.

After the fluid was drained, a chest radiograph showed minimal effusion on the right side. On the second day, the patient complained he was having difficulty breathing and showed signs of poor air entry on the right side of his chest. A second radiograph was ordered and showed re-accumulation of right-sided fluid with concomitant pneumothorax (ie, hydropneumothorax). (Fig. 3)

ADDITIONAL TREATMENT

Because of recurrent accumulation of fluid, we decided to perform video-assisted thoracoscopic surgery (VATS) with ligation of the thoracic duct. The procedure, along with pleurodesis, was successful and an intercostal drainage tube was inserted and left in situ. During the surgery, we removed fluid

containing 235 mg/dL of triglyceride. During the first week after surgery, the chest tube continued to drain around 1 liter per day.

Once the drainage decreased to between 400-500 mL per day, we removed the intercostal drainage tube and the patient remained in the hospital for a few days for observation. His blood counts were normal, there was no re-accumulation of fluid, the fluid triglyceride levels were 24 mg/dL and 25 mg/dL on two occasions, he had no pleural fluid collection, and a normally functioning pacemaker. However, his chest radiograph showed residual pleural thickening on the right side. (Fig. 4)

The patient was considered stable and was discharged on oral anticoagulants, amlodipine 5 mg daily and torsemide 10 mg daily. One month following his discharge, he continued to be afebrile.

Fig. 2 Fig. 3

Fig. 4

CONCLUSIONS

The difficulty we encountered while placing the pacemaker lead, which necessitated serial dilatations of the tract to insert the venous sheath in the infra clavicular region, seems to have injured the thoracic duct or one of its tributaries. This, possibly, combined high venous pressures (due to thrombosis of neck veins on his left side and restricted drainage from a partially occluded right subclavian vein), could have contributed to the outpouring of chyle into the pleural cavity.

Professor Kaul is a highly recognized name, both nationally and internationally, for his work in cardiovascular sciences. He is known as a passionate teacher and an astute clinician who is credited with starting the coronary angioplasty program in India and continues to bring innovative techniques in interventional cardiology to the country. He was also on the faculty of G B Pant Hospital, PGIMER Chandigarh and AIIMS where he was a Professor of Cardiology. He has been involved in several public education programs all over the country, including in his place of birth in Kashmir.

He established cardiology units at several hospitals in government and the private sector. These include C T Center AIIMS, Batra Hospital, Fortis hospitals NOIDA, Vasant Kunj and SSIHMS at Puttaparthy, AP. Professor Kaul has trained more than 400 cardiologists and has authored more than 400 papers and written many books. He is a visiting professor to several overseas universities.

* Recommendation subject to change based on new evidence. Consult UpToDate subscription for most current recommendation.

UPTODATE RECOMMENDS

For pocket infection and/or device-associated endocarditis, UpToDate recommends explantation of the device and all associated leads, in association with appropriate antibiotic therapy. If a new device is required, it should be implanted via an uninfected route if possible.*

For patients with a traumatic chylothorax (eg, nonsurgical or postoperative) and large volume drainage of chylous fluid (>1 L per day) who can tolerate surgery, UpToDate recommends early thoracic duct ligation (eg, within 3 to 7 days). Pleurodesis may be performed at the time of thoracic duct ligation via mechanical abrasion or insufflation of talc. Thoracic duct embolization or disruption where available are additional approaches.

He is a fellow of several prestigious societies in cardiology, both nationally and internationally, and has delivered many named orations. He has held the posts of President of Cardiological Society of India and SAARC Cardiac Society. He was also a foundering member of the Asia Pacific Society of Interventional Cardiology.

Currently, Professor Kaul is the Co-Chairman of the Credentials Committee of the SCAI, USA and Course director of Asia PCR/SingLIVE. He is also Editor in Chief of the journal ASIA Interventions and Fortis Medical Journal.

Professor Kaul has been the principal investigator of several national and international clinical research trials. He is the first Indian Cardiologist to initiate Investigator-initiated multicentric trials; one of his recent trials, TUXEDO-India, has received international recognition, which included a late breaking trial at the TCT 2015 and a publication in NEJM. Among his numerous recognitions, Professor Kaul has also been awarded the coveted Dr. B C Roy Award and Padamshiri from the President of India.

“For complex cases like these, I am happy to have a resource like UpToDate to answer my clinical questions and reassure me that the treatment and diagnostic decisions I make are based on the most current and relevant clinical evidence.”

— Professor Upendra Kaul, MD

BIOGRAPHY

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