Introduction: Cardiac device-related infective en-docarditis (CDRIE) represents a severe complication, associated with high mortality (8%). The diagnosis can be challenging, the symptoms being non-specific in many cases. CDRIE must be suspected in patients with fever or low fever and cardiac implantable electronic devices. The most frequent encountered species is Staphylococcus (60-80%), especially coagulase-negative species. Septic embolism represents one of the complications of cardiac device related-infective endocarditis, typically being confined to the pulmonary circulation. Although rare, systemic embolism is possible in the presence of an interatrial communication. The only known curative treatment, besides prolonged antibiotic therapy, is the complete removal of the device and the leads, transvenous lead extraction being the method of choice.

Case presentation: We present the case of a 60-year-old woman, hospitalized for rapid palpitations and low fever. The patient has a history of permanent cardiac pacing (VVI) for tachybrady syndrome (atrial fibrilla-tion and multiple flutters, symptomatic sinus bradycardia after conversion) and a history of recent cardioem-bolic myocardial infarction and mesenteric ischemia. Both embolic ischemic events occurred under anticoagulant treatment (dabigatran, respectively acenocu-marol and coumarin overdose). Physical examination showed no signs of heart failure or inflammatory chan-ges at the generator pocket. At admission, the patient had atrial fibrillation with rapid ventricular rate, sub-sequently converted to sinus rhythm. Laboratory values showed elevated markers of inflammation, mild anemia, slight increase in serum creatinine and one set of blood cultures was positive for coagulase-nega-tive Staphylococcus. Transthoracic echocardiography showed a suggestive image for vegetation attached to the atrial segment of the pacemaker lead, of 7 mm, without intracardiac thrombosis and without other signi-ficant changes, elements confirmed by transesophageal echocardiography. It also showed patent foramen ovale. Based on the above criteria, the diagnosis of infective endocarditis was established. The antibiotic therapy with vancomycin and aminoglycosides was initiated. Subsequently, the complete hardware removal was performed, with transvenous lead extraction. After completing six weeks of antibiotic therapy, a dual-chamber pacemaker was reimplanted on the contralateral side.

Particularity: This presentation illustrated the case of a patient with multiple systemic embolisms, under anticoagulant treatment, the most likely source being the vegetation attached to the pacemaker lead located in the right heart. Paradoxical systemic embolism is rare, but possible in the presence of an interatrial communication. However, thrombotic embolism cannot be ruled out.