A case report of pacemaker endocarditis presenting as osteitis in a high-surgical-risk patient: a management challenge with thromboaspiration and leadless pacemaker implantation.

BACKGROUND: Cardiac implantable electronic device-related infective endocarditis is a serious and increasingly frequent complication, often presenting atypically in frail patients with multiple comorbidities. CASE SUMMARY: We report the case of an 83-year-old man admitted with fever and heel pain, who developed heart failure symptoms. Investigations revealed Staphylococcus aureus bacteraemia, osteitis, spondylodiscitis, and a large tricuspid valve vegetation (26 mm) attached to the pacemaker lead, complicated by pulmonary embolism. Given his high surgical risk and resistant Gram-positive bacteraemia, a multidisciplinary endocarditis team opted for percutaneous vegetation thromboaspiration and complete device extraction, and pacing was ensured via an externalized temporary-permanent pacing system. After infection clearance, a leadless pacemaker was successfully implanted. The clinical outcome was favourable, with no recurrence or complications on follow-up. CONCLUSION: This case emphasizes the importance of early suspicion, advanced imaging, and tailored management of cardiac implantable electronic device-related endocarditis. Leadless pacemakers and percutaneous aspiration represent valuable strategies in high-risk patients to reduce infection recurrence and embolic risk.