[99mTc]Tc-HMPAO-WBC detection of cardiac implantable electronic device infection mimicking nST acute myocardial infarction

Document Type : Case Report


Nuclear Medicine Department, Cardiology Research Institute, Branch of the Federal State Budgetary Scientific Institution, Tomsk National Research Medical Center of the Russian Academy of Sciences, Tomsk, Russian Federation


Сardiac implantable electronic device infection (CIED) is a rare complication, ranging from 0.5-1% in the first 6-12 months after device implantation. In the absence of a standardised protocol, the diagnosis of CIED infection is difficult due to a nonspecific clinical presentation. In some cases, the inflammatory process can mimicking as another cardiovascular disorder, including acute myocardial infarction. Today, the diagnosis of infection is based on the Duke criteria, including clinical, microbiological and echocardiographic data. However, the diagnostic accuracy of the criteria for device-related infective endocarditis is significantly reduced. Presented clinical case highlights the importance of increased vigilance in patients who have undergone device implantation and, in particular, device replacement, and the usefulness of nuclear imaging techniques in asymptomatic patients or patients with an atypical clinical picture.


Main Subjects

  1. Habib G, Lancellotti P, Antunes MJ, Bongiorni MG, Casalta JP, Del Zotti F, Dulgheru R, El Khoury G, Erba PA, Iung B, Miro JM, Mulder BJ, Plonska-Gosciniak E, Price S, Roos-Hesselink J, Snygg-Martin U, Thuny F, Tornos Mas P, Vilacosta I, Zamorano JL; ESC Scientific Document Group. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J. 2015 Nov 21;36(44):3075-128.
  2. Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GCM; ESC Scientific Document Group. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021 Apr 7;42(14):1289-367.
  3. de Vries EF, Roca M, Jamar F, Israel O, Signore A. Guidelines for the labelling of leucocytes with (99m)Tc-HMPAO. Inflammation/Infection Taskgroup of the European Association of Nuclear Medicine. Eur J Nucl Med Mol Imaging. 2010 Apr;37(4):842-8.
  4. Erba PA, Sollini M, Conti U, Bandera F, Tascini C, De Tommasi SM, Zucchelli G, Doria R, Menichetti F, Bongiorni MG, Lazzeri E, Mariani G. Radiolabeled WBC scintigraphy in the diagnostic workup of patients with suspected device-related infections. JACC Cardiovasc Imaging. 2013 Oct;6(10):1075-86.
  5. Welch M, Uslan DZ, Greenspon AJ, Sohail MR, Baddour LM, Blank E, Carrillo RG, Danik SB, Del Rio A, Hellinger W, Le KY, Miro JM, Naber C, Peacock JE, Vikram HR, Tseng CH, Prutkin JM; MEDIC Investigators. Variability in clinical features of early versus late cardiovascular implantable electronic device pocket infections. Pacing Clin Electrophysiol. 2014 Aug;37(8):955-62.
  6. Nielsen JC, Gerdes JC, Varma N. Infected cardiac-implantable electronic devices: prevention, diagnosis, and treatment. Eur Heart J. 2015 Oct 1;36(37):2484-90.
  7. Kirkfeldt RE, Johansen JB, Nohr EA, Jørgensen OD, Nielsen JC. Complications after cardiac implantable electronic device implantations: an analysis of a complete, nationwide cohort in Denmark. Eur Heart J. 2014 May;35(18):1186-94.
  8. Blomström-Lundqvist C, Traykov V, Erba PA, Burri H, Nielsen JC, Bongiorni MG, Poole J, Boriani G, Costa R, Deharo JC, Epstein LM, Saghy L, Snygg-Martin U, Starck C, Tascini C, Strathmore N; ESC Scientific Document Group. European Heart Rhythm Association (EHRA) international consensus document on how to prevent, diagnose, and treat cardiac implantable electronic device infections-endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), the Latin American Heart Rhythm Society (LAHRS), International Society for Cardiovascular Infectious Diseases (ISCVID) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Europace. 2020 Apr 1;22(4):515-549.
  9. Wilkoff BL, Love CJ, Byrd CL, Bongiorni MG, Carrillo RG, Crossley GH 3rd, Epstein LM, Friedman RA, Kennergren CE, Mitkowski P, Schaerf RH, Wazni OM; Heart Rhythm Society; American Heart Association. Transvenous lead extraction: Heart Rhythm Society expert consensus on facilities, training, indications, and patient management: this document was endorsed by the American Heart Association (AHA). Heart Rhythm. 2009 Jul;6(7):1085-104.
  10. Aguilera J, Hutt E, Jaber WA. Imaging of cardiac device-related infection. Front Cardiovasc Med. 2021 Aug 24;8:729786.
  11. Toriello F, Saviano M, Faggiano A, Gentile D, Provenzale G, Pollina AV, Gherbesi E, Barbieri L, Carugo S. Cardiac implantable electronic devices infection assessment, diagnosis and management: a review of the literature. J Clin Med. 2022 Oct 6;11(19):5898.
  12. Polewczyk A, Janion M, Kutarski A. Cardiac device infections: definition, classification, differential diagnosis, and management. Pol Arch Med Wewn. 2016 Apr 13;126(4):275-83.
  13. Holcman K, Małecka B, Rubiś P, Ząbek A, Szot W, Boczar K, Leśniak-Sobelga A, Hlawaty M, Wiśniowska-Śmiałek S, Stępień A, Podolec P, Kostkiewicz M. The role of 99mTc-HMPAO-labelled white blood cell scintigraphy in the diagnosis of cardiac device-related infective endocarditis. Eur Heart J Cardiovasc Imaging. 2020 Sep 1;21(9):1022-30.
  14. Golzio PG, Errigo D, Peyracchia M, Gallo E, Frea S, Castagno D, Budano C, Giustetto C, Rinaldi M. Prevalence and prognosis of lead masses in patients with cardiac implantable electronic devices without infection. J Cardiovasc Med (Hagerstown). 2019 Jun;20(6):372-8.
  15. Caobelli F, Wollenweber T, Bavendiek U, Kühn C, Schütze C, Geworski L, Thackeray JT, Bauersachs J, Haverich A, Bengel FM. Simultaneous dual-isotope solid-state detector SPECT for improved tracking of white blood cells in suspected endocarditis. Eur Heart J. 2017 Feb 7;38(6):436-43.
  16. Małecka BA, Ząbek A, Dębski M, Szot W, Holcman K, Boczar K, Ulman M, Lelakowski J, Kostkiewicz M. The usefulness of SPECT-CT with radioisotope-labeled leukocytes in diagnosing lead-dependent infective endocarditis. Adv Clin Exp Med. 2019 Jan;28(1):113-9.