This 70-year-old male had been a heavy smoker since his youth and suffered from chronic obstructive pulmonary disease (COPD). About 30 years previously, he was diagnosed with arterial hypertension and type 2 diabetes mellitus. He had problems with the peripheral circulation, and 10 years earlier necrosis had started to affect his toes and feet. He was treated with percutaneous transluminal angioplasty of the stenotic femoral arteries, in addition to amputation of the right forefoot and the left crus. In his last year, ischemic and infected wounds again developed on his right foot. He also had psoriatic affection of the skin. One year previously, while on vacation abroad, he suffered a myocardial infarction. Coronary angiography (CAG) showed stenosis of the left main artery (LM), the left anterior descendent artery (LAD), and the proximal circumflexus artery (CX), and he was treated with percutaneous coronary intervention (PCI) and stents. EF 25% and reduced right ventricular function. Sinus rhythm and left bundle branch block 174 ms. (Figure 1).

  The patient received treatment with an angiotensin-converting enzyme inhibitor, beta-blocker, diuretics, statin, and salicylate and was scheduled implantation with a CRT-D. Before this could be realized, however, he was admitted with ACS with EF dropping to 10% and protracted cardiogenic shock with multiorgan dysfunction. Restenosis was revealed in the stented areas and treated with balloon angioplasty. He slowly recuperated. 

 About two months later, he suffered another ACS and in addition to severe in-stent restenosis, corresponding to severe stenosis in the distal LM, the ostial LAD, and the proximal CX, a stenosis in the proximal right coronary artery (RCA) was also detected (Figure 2). He was in a poor state and performing PCI or coronary artery bypass grafting (CAGB) posed a very high risk; instead medical treatment was recommended. His condition remained unstable and characterized by angina pectoris, dyspnea and problems with comorbidities. Due to the poor prognosis, a limited level of treatment was decided in consultation with the patient and his family. This decision was re-evaluated on an ongoing basis.  

  Implantation of a CRT-D was postponed due to septicemia with Staphylococcus aureus, which was cultivated from the blood and from the wound on his right foot. He was administered antibiotic therapy. Three weeks later, all signs of infection had disappeared. However, the leg wound was not completely closed, but the biochemical screenings values were normal. The CRT-D was implanted without complications (an antibacterial envelope was not used). The patient improved, his shortness of breath subsided from NYHA III to NYHA II, and the QRS-duration diminished to 146 ms. (Figure 3).

 As the next step, CABG was planned, but had to be postponed due to recidivating septicemia and infection without a recognized focus. Staphylococcus aureus, Staphylococcus epidermidis, and Corynebacterium were cultivated from the blood. Transesophageal echocardiography revealed discrete changes related to a pace lead, no typical vegetations and no valvular involvement. Positron emission tomography-computerized tomography (PET-CT) showed a change in the same area. Specialists were called upon to evaluate the patient, and it was finally concluded that the infection was probably related to the pacemaker, and system extraction was mandated. Percutaneous explantation was performed, 6 weeks after the implantation, by an experienced operator, with simple traction of the leads, and without procedural complications; a few hours later, however, he began to develop shock with falling bloodpressure, and his temperature rose to 38.5. Monitoring echocardiography showed a drop in ejection fraction (EF) from 20% to 5% despite intensive care.He exhibited no pericardial effusion. His condition deteriorated rapidly, and implantation of a new “rescue” CRT was not considered a possibility. In addition, revascularization could have been a solution, but with a very high risk and it was rejected due to his poor condition and the comorbidities. Extracorporeal membrane oxygenation (ECMO) and impella were not an option due to the peripheral vascular disease.He did not respond to vasopressor therapy (norepinephrine) and died within 17 hours of surgery.