A RARE CASE OF PACEMAKER LEAD-ASSOCIATED THROMBOSIS IN AN ANTICOAGULATED PATIENT

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Cardiac implantable electronic devices (CIED) can be complicated by thrombus formation. Those complications are rare, with an incidence of 1.4% and carries increased risk morbidity mortality. [1] CASE PRESENTATION: The patient is a 66-year-old female past medical history significant for hypertension, sick sinus syndrome, post-dual chamber pacemaker implantation ten years ago on chronic anticoagulation Warfarin. She presented to the emergency department worsening dyspnea exertion two weeks. Review systems was bloody stool. vitally stable. Physical examination showed clear lungs, normal heart sounds, no stigmata infective endocarditis. Lab work iron deficiency anemia, otherwise troponin, mildly elevated BNP therapeutic INR. Electrocardiogram left axis deviation biventricular paced rhythm. managed blood transfusion, holding Warfarin gastrointestinal workup positive internal external bleeding hemorrhoids. Despite normalization her hemoglobin, shortness breath continued evolve, she started complain chest pain, so cardiology consulted. A transthoracic echocardiogram 2.7x2.5cm mass in right atrium attached tricuspid valve. Blood cultures were negative. Transesophageal echocardiography confirmed large mobile consistent lead. Empiric antibiotics initiated cover culture-negative Anticoagulation could not setting recent bleeding. decision made refer cardiothoracic surgeon order prevent clot from forming releasing subsequent saddle pulmonary embolus. Eventually, removed, subsequently recovered. DISCUSSION: thrombi cardiac device lead extremely rare. pathogenesis thrombosis related implanted remains controversial, as well its clinical significance. [2] Pacemaker leads may cause endothelial injury turbulent flow like any other intravascular device. This induce platelet aggregation fibrin deposition, additionally produce foreign-body-type reaction inflammation; Treatment controversial based size thrombus. Small sized while larger clots require additional options, such thrombolysis or surgical approach. Our belonged latter who surgery. CONCLUSIONS: case highlights non-specific presentation potentially lethal formation after CIED; low index suspicion should kept promptly identify this complication, even when patients anticoagulation. REFERENCE #1: Rahbar AS, Azadani PN, Thatipelli S, et al. Risk factors prognosis leads. Pacing Clin Electrophysiol. 2013;36:1294–1300 #2: Monzo L, Silvetti E, Maresca Della Bona R, De Ruvo Calò L. Walking Thrombus. Acta Cardiol Sin. 2020;36(1):81-83. doi:10.6515/ACS.202001_36(1).20190823A DISCLOSURES: No relevant relationships Abdul Rahman Al Armashi, source=Web Response Dina Haroun, Mohamed Homeida, Kanchi Patell, Keyvan Ravakhah,