Tricuspid endocarditis in an adult patient with Ebstein’s anomaly who has a residual pacemaker lead Ahmet Kaya Bilge, Kamil Adalet, Tolga O ¨ zyig˘it, Beste O ¨ zben & Ercu¨ment Yılmaz Department of Cardiology, University of Istanbul, Istanbul Faculty of Medicine, Istanbul, Turkey Received 14 November 2004; accepted in revised form 25 February 2005 Key words: Ebstein’s anomaly, endocarditis, residual pacemaker lead, atrial flutter Abstract Ebstein’s anomaly is defined as an apical displacement of the attachment of the septal tricuspid valve leaflet from the right atrioventricular annulus that exceeded 1.2 cm in length. Patients with Ebstein’s anomaly are known to have a high potential for developing arrhythmia, in the vast majority, of the tachycardia type. Infective endocarditis is characterized by ulcerovegetational lesions that result from the graft of a micro- organism, usually bacterial, on the valvuler endocardium (native valve endocarditis) or on a prosthesis (prosthetic valve endocarditis). Ebstein’s anomaly with tricuspid regurgitation is also thought to be a predisposing condition for infective endocarditis. In this case, we report a patient who presented with atrial flutter and infective endocarditis due to residual pacemaker lead and Ebstein’s anomaly. Case report A 58-year-old male patient applied to the hospital with the compliant of weakness, palpitation, shivering and fever lasting for more than 1 month and reaching 39 °C. AAI type pacemaker was implanted due to sick sinus syndrome 18 years ago but the generator was removed 5 years ago due to local pacemaker site infection and the lead was left. In physical examination; venous distention and 3/6 grade pansystolic murmur at the meso- cardiac area were present. In the electrocardio- gram, there was atrial flutter with alternating 3:1– 4:1 AV conduction and an average ventricular rate of 75–80/min. In transthoracic echocardiography, downward placement of the septal leaflet of the tricuspid valve appropriate with the Ebstein’s anomaly and the atrialization of the ventricular segment in this region were seen (Figure 1). At the tricuspid valve, a large (2.5 cm), mobile vegetation and severe valve regurgitation were detected (Figures 2 and 3). In the hemocultures taken in the febrile periods, methicillin sensitive coagulase negative staphylococcus aureus was obtained. In accordance with the antibiogram, the treatment of first generation cephalosporin and gentamycine was given the patient with the diagnosis of tri- cuspid valve endocarditis. Fever and the systemic signs disappeared at the fifth day of treatment, but surgery was planned due to the presence of large vegetation and severe valve dysfunction. During operation, we have found that the vegetation derived from the septal leaflet of tricuspid valve. The residual pacemaker lead was removed surgi- cally, tricuspid valve replacement was performed and intraoperatively linear radiofrequency abla- tion was done between tricuspid annulus and inferior vena cava for atrial flutter treatment. Pa- tient was discharged from hospital without any complication and his final rhythm was sinus. The International Journal of Cardiovascular Imaging (2005) 21: 641–643 DOI 10.1007/s10554-005-2825-3 Ó Springer 2005