Strains of a Virtuoso: Pacemaker Infection and Ventricular Tachycardia in a Violinist

Strains of a Virtuoso: Pacemaker Infection and Ventricular Tachycardia in a Violinist | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Strains of a Virtuoso: Pacemaker Infection and Ventricular Tachycardia in a Violinist Yuanguo Chen, Haibo Zhang, Qi Qiao, Lian Ma This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5245487/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 23 Jan, 2025 Read the published version in BMC Cardiovascular Disorders → Version 1 posted 16 You are reading this latest preprint version Abstract Purpose Pacemaker-related infections are serious complications of cardiac implantable electronic devices (CIEDs)1–5. This case report aims to describe the occurrence of pacemaker pocket infection and recurrent ventricular tachycardia (VT) in a Chinese amateur violinist with sick sinus syndrome (SSS), and to explore the possible connection between occupational habits and the infection, as well as VT. Methods A 76-year-old male violinist with a Biotronik Evia DR dual-chamber pacemaker presented with syncope and signs of a pacemaker pocket infection three years after implantation. Despite initial antibiotic treatment, the infection persisted with slightly elevated C-reactive protein (CRP) and negative cultures. The VT originated from the right ventricular outflow tract (RVOT), as confirmed by echocardiography and ECG findings. The infection was treated with debridement and extraction of the pacemaker and leads. Results Debridement and extraction of the pacemaker and leads successfully resolved both the VT and the infection. The VT was likely linked to the infected lead, while the pacemaker infection was attributed to the patient’s violin playing, which caused mechanical stress and skin damage at the pacemaker site. Postoperative recovery was uneventful, with no recurrence of infection or arrhythmias at follow-up. Conclusion This case highlights the importance of considering a patient’s occupational habits when selecting pacemaker pocket sites to prevent infections and complications. In this case, the patient's violin playing likely contributed to mechanical stress at the pacemaker site, leading to infection. Early identification and appropriate management, including device removal, are crucial to prevent further complications. Pacemaker infection Ventricular tachycardia Lead extraction Sick sinus syndrome Occupational habits Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Case Presentation Patient Information: A 76-year-old male Chinese amateur violinist with a history of sick sinus syndrome received an Evia DR (Pro MRI) dual-chamber pacemaker manufactured by Biotronik three years prior. Post-implantation, the electrocardiogram (ECG) showed AAI pacing mode (Fig. 1). Symptoms and Initial Treatment: Three years after implantation, the patient presented with syncope, localized redness, and pain due to pacemaker pocket infection and exposure under the left clavicle. Despite antibiotic treatment at a local hospital, the infection persisted (Fig. 2). Laboratory tests showed slightly elevated CRP but normal white blood cell count and other parameters. Blood cultures and pocket discharge cultures were negative. The patient presented with localized redness, pain, and syncope. ECG indicated recurrent VT (Fig. 3 and Fig. 4). Laboratory tests showed normal white blood cell count, liver and kidney function, electrolytes, and coagulation profiles. CRP was slightly elevated. Initial diagnosis was pacemaker pocket infection. Echocardiography (Fig. 5) and chest X-ray (Fig. 6) confirmed that the ventricular lead was positioned at the free wall of the right ventricular outflow tract, where the VT originated. Interventional Procedure: Debridement and percutaneous extraction of the pacemaker and leads were performed. The extraction process involved counterclockwise rotation to detach the leads from myocardial tissue (Fig. 7). During the procedure,VT occurred but was managed successfully. Post-procedure, the patient received broad-spectrum antibiotics. Outcome: The patient's VT resolved, and no further syncope episodes occurred. Postoperative ECG indicated sinus rhythm with a ventricular rate of 50–60 bpm (Fig. 8). The patient was discharged on postoperative day 7 with no recurrence of infection or arrhythmia at follow-up. Discussion This case report presents a unique scenario of a delayed pacemaker pocket infection occurring three years post-implantation, without positive cultures for any specific pathogen. The absence of pathogen growth in blood and local secretion cultures is particularly notable and warrants discussion. Several factors could contribute to this finding 6 . Firstly, the patient's prior antibiotic treatment at a local hospital before cultures were taken could have suppressed bacterial growth, making it difficult to identify the causative agent. Additionally, the nature of the infection, possibly being subacute or chronic due to the extended period post-implantation, might have led to low bacterial loads that are difficult to culture. The patient's profession as a violinist involves repetitive use of the left shoulder, which likely contributed to mechanical wear and erosion at the pacemaker site, increasing the risk of infection. However, the absence of detectable pathogens in the cultures suggests that the inflammatory response could be partially due to non-infectious factors such as mechanical irritation, although the clinical presentation and response to antibiotics indicate an infectious process. The unique presentation of VT in this case was associated with the pacemaker lead's positioning in the right ventricular outflow tract, suggesting that the inflammation around the lead, whether infectious or mechanically induced, could exacerbate arrhythmogenicity 7–9 . Although the patient's ventricular tachycardia (VT) ECG characteristics are not typical, they still suggest a likely origin from the right ventricular outflow tract (RVOT) free wall. The variability in QRS morphology, with lead I showing Rs pattern to rS pattern, leads II, III, aVF showing R pattern, lead V1 showing R pattern, and lead V2 showing rS pattern, may be due to local electrode movement or regional cardiac conduction variations. The termination of VT upon removal of the RVOT free wall electrode further supports this origin despite the atypical ECG presentation 10 . The resolution of symptoms following the removal of the device and administration of antibiotics supports the infectious nature of the inflammation, but also highlights the complexity of diagnosing and treating device-related infections when standard cultures fail to identify a pathogen 11 . The gradual changes in QRS morphology observed during ventricular tachycardia (VT) in this patient with a right ventricular outflow tract (RVOT) pacemaker lead suggest variable contact between the lead tip and myocardial cells. Despite these morphological changes, the VT frequency remains constant, indicating a stable pacing source likely at the lead tip. These observations are independent of body position changes, reinforcing that the QRS variations are due to local contact variations rather than positional changes of the heart. This phenomenon underscores the significant impact of lead tip positioning on QRS waveform characteristics 12–14 . Removing a pacemaker lead three years post-implantation carries a risk of cardiac perforation. However, due to pacemaker pocket and lead infection, removal was necessary. We meticulously prepared for potential complications, including pericardiocentesis and cardiac surgery readiness for emergency open-heart intervention. The extraction of the screw-in lead proceeded smoothly, and the patient experienced no postoperative complications such as pericardial effusion 15–17 . Given the lack of positive cultures, the decision to use broad-spectrum antibiotics was prudent and based on the common pathogens associated with pacemaker infections, primarily Staphylococcus species. This approach is justified in cases where clinical signs of infection are evident, but no specific pathogens are identified, as it covers a broad range of potential bacteria. The management of the infection through device removal and broad-spectrum antibiotic therapy 18, 19 , in this case, was effective, underlining the importance of a comprehensive approach to suspected infections, especially when empirical treatment is necessary. This case emphasizes the need for careful assessment of occupational factors that may compromise implant sites and highlights the challenges of managing infections when culture results are negative 20 . Conclusion This case highlights the link between pacemaker infections and occupational habits, and the arrhythmias related to lead positioning. The patient's violin playing likely caused mechanical stress, leading to infection. Additionally, the ventricular lead's position contributed to arrhythmias. Effective treatment must consider these factors, including broad-spectrum antibiotics and careful lead placement. Declarations Author Declarations Funding This work was supported by a grant from the Key Science and Technology Project of Ya'an City, with project number 22KJJH0038. Conflicts of Interest None of the authors has any conflict of interest related to this manuscript. Ethics Approval Not applicable. Consent to Participate Written informed consent was obtained from the patient for participation in this case report. Consent for Publication Written informed consent was obtained from the patient for the publication of this case report, including any associated images. Availability of Data and Materials All relevant data supporting the conclusions of this article are included within the manuscript. Code Availability (software application or custom code) Not applicable. Clinical trial number: not applicable. Authors' Contributions All authors contributed to the conception and design of the case report. Yuanguo Chen led the writing of the manuscript and coordinated the case report. Haibo Zhang and Qi Qiao were responsible for clinical data collection and analysis. Lian Ma supervised the study and revised the manuscript critically for intellectual content. All authors have read and approved the final version of the manuscript. References Voigt A, Shalaby A and Saba S. Rising Rates of Cardiac Rhythm Management Device Infections in the United States: 1996 through 2003. Journal of the American College of Cardiology . 2006;48:590-591. Da Costa A, Lelièvre H, PhaD, Kirkorian G, Célard M, Chevalier P, Vandenesch Fo, Etienne J and Touboul P. Role of the Preaxillary Flora in Pacemaker Infections. Circulation . 1998;97:1791-1795. Dilsizian V, Budde RPJ, Chen W, Mankad SV, Lindner JR and Nieman K. Best Practices for Imaging Cardiac Device–Related Infections and Endocarditis. JACC: Cardiovascular Imaging . 2022;15:891-911. Kumar P, Skrabal J, Frasure SE and Pourmand A. Pacemaker lead related myocardial perforation. The American Journal of Emergency Medicine . 2022;53:281.e1-281.e3. Curtis AB and Ahmed A. Treatment of Localized Implantable Cardiac Device Pocket Infections. Journal of the American College of Cardiology . 2023;81:134-135. Mela T, McGovern BA, Garan H, Vlahakes GJ, Torchiana DF, Ruskin J and Galvin JM. Long-term infection rates associated with the pectoral versus abdominal approach to cardioverter- defibrillator implants. The American Journal of Cardiology . 2001;88:750-753. Wisoff BG. Pacemaker-Induced Ventricular Tachycardia. JAMA: The Journal of the American Medical Association . 1965;192. Atlee JL and Bernstein AD. Runaway Temporary Pacemaker. New England Journal of Medicine . 1980;302:1030-1031. Bauer A. Imitating ventricular tachycardia. Heart . 2003;89:1382-a-1382. Landreville JM, Joubert GI, Welisch E, Helleman K and Poonai NP. Atypical Presentation of Right Ventricular Outflow Tract Ventricular Tachycardia. J Emerg Med . 2015;49:432-5. DeSimone DC and Sohail MR. Management of bacteremia in patients living with cardiovascular implantable electronic devices. Heart Rhythm . 2016;13:2247-2252. Castellanos A, Jr. and Lemberg L. Cardiac arrhythmias. 6. Pacemaker arrhythmias and electrocardiographic recognition of pacemaker. Circulation . 1973;47:1382-91. Escher DJ. Types of pacemakers and their complications. Circulation . 1973;47:1119-31. Erdinler I, Okmen E, Zor U, Zor A, Oguz E, Ketenci B, Akyol A, Aytekin S and Ulufer T. Pacemaker related endocarditis: analysis of seven cases. Jpn Heart J . 2002;43:475-85. Zhang J, He L, Xing Q, Zhou X, Li Y, Zhang L, Lu Y, Tuerhong Z, Yang X and Tang B. Evaluation of safety and feasibility of leadless pacemaker implantation following the removal of an infected pacemaker. Pacing Clin Electrophysiol . 2021;44:1711-1716. Ruttmann E, Hangler HB, Kilo J, Hofer D, Muller LC, Hintringer F, Muller S, Laufer G and Antretter H. Transvenous pacemaker lead removal is safe and effective even in large vegetations: an analysis of 53 cases of pacemaker lead endocarditis. Pacing Clin Electrophysiol . 2006;29:231-6. Farooqi FM, Talsania S, Hamid S and Rinaldi CA. Extraction of cardiac rhythm devices: indications, techniques and outcomes for the removal of pacemaker and defibrillator leads. International Journal of Clinical Practice . 2010;64:1140-1147. Baddour LM, Epstein AE, Erickson CC, Knight BP, Levison ME, Lockhart PB, Masoudi FA, Okum EJ, Wilson WR, Beerman LB, Bolger AF, Estes NAM, Gewitz M, Newburger JW, Schron EB and Taubert KA. Update on Cardiovascular Implantable Electronic Device Infections and Their Management. Circulation . 2010;121:458-477. Ben Abid F, Al-Saoub H, Howadi F, AlBishawi A and Thapur M. Delayed Pacemaker Generator Pocket and Lead Primary Infection Due to Burkholderia Cepacia. American Journal of Case Reports . 2017;18:855-858. Sohail MR, Uslan DZ, Khan AH, Friedman PA, Hayes DL, Wilson WR, Steckelberg JM, Stoner S and Baddour LM. Management and Outcome of Permanent Pacemaker and Implantable Cardioverter-Defibrillator Infections. Journal of the American College of Cardiology . 2007;49:1851-1859. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 23 Jan, 2025 Read the published version in BMC Cardiovascular Disorders → Version 1 posted Editorial decision: Revision requested 12 Nov, 2024 Reviews received at journal 11 Nov, 2024 Reviewers agreed at journal 11 Nov, 2024 Reviews received at journal 11 Nov, 2024 Reviews received at journal 10 Nov, 2024 Reviewers agreed at journal 10 Nov, 2024 Reviewers agreed at journal 08 Nov, 2024 Reviewers agreed at journal 06 Nov, 2024 Reviews received at journal 06 Nov, 2024 Reviewers agreed at journal 06 Nov, 2024 Reviewers agreed at journal 06 Nov, 2024 Reviewers agreed at journal 06 Nov, 2024 Reviewers invited by journal 06 Nov, 2024 Editor assigned by journal 22 Oct, 2024 Submission checks completed at journal 21 Oct, 2024 First submitted to journal 11 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5245487","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":377272454,"identity":"7541d13c-1c08-4365-b7d1-0d6c7bb6892c","order_by":0,"name":"Yuanguo Chen","email":"","orcid":"","institution":"Ya'an People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yuanguo","middleName":"","lastName":"Chen","suffix":""},{"id":377272455,"identity":"03f0ff1d-db42-4002-a839-42eb6f4e88bf","order_by":1,"name":"Haibo Zhang","email":"","orcid":"","institution":"Ya'an People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Haibo","middleName":"","lastName":"Zhang","suffix":""},{"id":377272456,"identity":"f439ea68-3613-4fc8-8003-6d53366e0658","order_by":2,"name":"Qi Qiao","email":"","orcid":"","institution":"Ya'an People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Qi","middleName":"","lastName":"Qiao","suffix":""},{"id":377272457,"identity":"3f80387c-e647-4da3-8ca1-e415c2045477","order_by":3,"name":"Lian Ma","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIiWNgGAWjYFAC5oYDDAw2cvzyhw8wJBCnhRGkJc1YcgZbAvFagMThxA0zeAyI06DbfrDxwM8daYkbpHs+f3i4w46Bv70bv2VmZxIbDvaesTHeLnN2m0TimWQGiTNnN+DXciCx4QBvW5rszobcbQyJbcwMBhK5BLScf9hw8G/bYcYNB3Ief0hsqydCy43EhsO8bYcVN9zIYZBIbDtMjJaHDYdl24CB3HPMDKjlOA9hv5xPPvzxbRswKtmbH3/82VYtx9/ei18LBuAhTfkoGAWjYBSMAqwAADMmU8ejnZOwAAAAAElFTkSuQmCC","orcid":"","institution":"Shenzhen Children's Hospital of China Medical University","correspondingAuthor":true,"prefix":"","firstName":"Lian","middleName":"","lastName":"Ma","suffix":""}],"badges":[],"createdAt":"2024-10-11 10:53:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5245487/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5245487/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12872-025-04495-0","type":"published","date":"2025-01-23T15:57:18+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":69418604,"identity":"3218398a-1d43-43ec-800c-503aaee08f35","added_by":"auto","created_at":"2024-11-20 07:27:51","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1311188,"visible":true,"origin":"","legend":"\u003cp\u003eThe electrocardiogram (ECG) post-pacemaker implantation demonstrates VAT pacing mode with an atrial pacing rate of 60 beats per minute. The ECG indicates effective atrial sensing, atrial triggering, and ventricular sensing without ventricular pacing.\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-5245487/v1/bed80556f7c4f54547207062.png"},{"id":69417473,"identity":"a63ae897-63af-474f-b66f-58e909d2e7c5","added_by":"auto","created_at":"2024-11-20 07:19:51","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":549194,"visible":true,"origin":"","legend":"\u003cp\u003ePanel A: An overall view of the patient's chest, showing the location of the pacemaker.\u003c/p\u003e\n\u003cp\u003ePanel B: A close-up of the pacemaker pocket.\u003c/p\u003e\n\u003cp\u003eThe images reveal a pacemaker pocket infection with exposed leads and visible skin necrosis around the area, indicating a severe infection.\u003c/p\u003e","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-5245487/v1/0476613cf4b6511f93c80dc2.png"},{"id":69417476,"identity":"ce3aba5b-35da-4e8b-8119-e28fdafc5e20","added_by":"auto","created_at":"2024-11-20 07:19:52","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":431508,"visible":true,"origin":"","legend":"\u003cp\u003eRecurrent ventricular tachycardia during the CCU hospitalization following pacemaker infection. The ECG tracings, recorded in standard lead II, highlight multiple episodes of ventricular tachycardia, indicating the severity of the arrhythmia associated with the pacemaker infection.\u003c/p\u003e","description":"","filename":"Fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-5245487/v1/d0b3c809f665df8ed2b61160.png"},{"id":69419035,"identity":"280c0aa9-ca60-41a6-91ae-dc6122e13913","added_by":"auto","created_at":"2024-11-20 07:35:52","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1538638,"visible":true,"origin":"","legend":"\u003cp\u003eStandard 12-lead electrocardiogram (ECG) recording of a ventricular tachycardia (VT) episode in the patient. The VT has a rate of approximately 190 beats per minute. In lead I, the QRS complex displays an R-wave pattern. Leads II, III, and aVF show predominantly positive QRS complexes with the main deflection being upward. The precordial leads (V1-V6) indicate an early transition, characterized by the shift of the QRS complex to a predominantly positive direction earlier than expected, suggesting the VT may originate from a location other than the typical right ventricular outflow tract (RVOT).\u003c/p\u003e","description":"","filename":"Fig4.png","url":"https://assets-eu.researchsquare.com/files/rs-5245487/v1/56ecdb6e9c042e67089d2c40.png"},{"id":69418609,"identity":"9ccf8ccf-62c8-471d-ad93-f747fc5fd78c","added_by":"auto","created_at":"2024-11-20 07:27:52","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":1131354,"visible":true,"origin":"","legend":"\u003cp\u003ePanel A:Parasternal short-axis view of the great arteries. Panel B:Parasternal long-axis view of the left ventricle.\u003c/p\u003e\n\u003cp\u003eIn both images, the blue arrows indicate the ventricular lead, while the star symbol marks the free wall of the right ventricle. The images demonstrate that the right ventricular lead is positioned at the free wall of the right ventricle, which is identified as the origin of the ventricular tachycardia.\u003c/p\u003e","description":"","filename":"Fig5.png","url":"https://assets-eu.researchsquare.com/files/rs-5245487/v1/a53d9fc1210d8fb2909fe09c.png"},{"id":69419033,"identity":"0f432d0b-cbca-41a8-afa1-d1d180695b6a","added_by":"auto","created_at":"2024-11-20 07:35:51","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":1148993,"visible":true,"origin":"","legend":"\u003cp\u003ehis figure is divided into three panels, illustrating the positioning of the pacemaker leads.\u003c/p\u003e\n\u003cp\u003ePanel A: Anteroposterior (AP) chest radiograph. This image shows the overall position of the pacemaker leads within the chest.\u003c/p\u003e\n\u003cp\u003ePanel B: Lateral chest radiograph. This side view provides additional detail on the spatial orientation of the leads.\u003c/p\u003e\n\u003cp\u003ePanel C: Left anterior oblique (LAO) view at 45 degrees under digital subtraction angiography (DSA). This fluoroscopic image highlights the specific locations of the pacemaker leads.\u003c/p\u003e\n\u003cp\u003eThe images collectively indicate that the right atrial lead is positioned in the right atrial appendage, while the right ventricular lead is situated in the right ventricular outflow tract, leaning towards the free wall rather than the interventricular septum. These details are critical for understanding the lead placement and potential implications for cardiac function and arrhythmia management.\u003c/p\u003e","description":"","filename":"Fig6.png","url":"https://assets-eu.researchsquare.com/files/rs-5245487/v1/ad10646f37066244f2494326.png"},{"id":69420597,"identity":"56e67b2f-3776-4c0d-a667-6638f48c0793","added_by":"auto","created_at":"2024-11-20 07:43:52","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":1129868,"visible":true,"origin":"","legend":"\u003cp\u003ePanel A: Extraction process of the right ventricular pacing lead. The lead is unscrewed from the myocardial tissue by rotating it counterclockwise and then gently pulled out of the body.\u003c/p\u003e\n\u003cp\u003ePanel B: Extraction process of the right atrial pacing lead. After the right ventricular lead has been removed, the right atrial lead is similarly rotated counterclockwise to disengage it from the atrial myocardial tissue and then carefully pulled out of the body.\u003c/p\u003e\n\u003cp\u003eThe blue arrows in both panels indicate the direction in which the leads are being pulled out of the body.\u003c/p\u003e","description":"","filename":"FIG7.png","url":"https://assets-eu.researchsquare.com/files/rs-5245487/v1/d5d30f1a1d3f9da8e589ba29.png"},{"id":69418606,"identity":"ff5b05ad-314f-439c-84e6-f59c1594daf7","added_by":"auto","created_at":"2024-11-20 07:27:52","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":1451045,"visible":true,"origin":"","legend":"\u003cp\u003eECG following the removal of the pacemaker leads. The ECG displays a sinus rhythm with a heart rate of 52 beats per minute. There are no episodes of ventricular tachycardia or ventricular premature contractions observed.\u003c/p\u003e","description":"","filename":"Fig8.png","url":"https://assets-eu.researchsquare.com/files/rs-5245487/v1/773ae9907a3f48acb2a9babc.png"},{"id":74858341,"identity":"75efa02d-2fd5-4e2a-9022-cfaf9412c4e9","added_by":"auto","created_at":"2025-01-27 16:08:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":9844599,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5245487/v1/fa9e8e14-c52e-4fa4-851d-a2837883077b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Strains of a Virtuoso: Pacemaker Infection and Ventricular Tachycardia in a Violinist","fulltext":[{"header":"Case Presentation","content":"\u003cp\u003ePatient Information:\u003c/p\u003e\u003cp\u003eA 76-year-old male Chinese amateur violinist with a history of sick sinus syndrome received an Evia DR (Pro MRI) dual-chamber pacemaker manufactured by Biotronik three years prior. Post-implantation, the electrocardiogram (ECG) showed AAI pacing mode (Fig.\u0026nbsp;1).\u003c/p\u003e\u003cp\u003eSymptoms and Initial Treatment:\u003c/p\u003e\u003cp\u003eThree years after implantation, the patient presented with syncope, localized redness, and pain due to pacemaker pocket infection and exposure under the left clavicle. Despite antibiotic treatment at a local hospital, the infection persisted (Fig.\u0026nbsp;2). Laboratory tests showed slightly elevated CRP but normal white blood cell count and other parameters. Blood cultures and pocket discharge cultures were negative. The patient presented with localized redness, pain, and syncope. ECG indicated recurrent VT (Fig.\u0026nbsp;3 and Fig.\u0026nbsp;4). Laboratory tests showed normal white blood cell count, liver and kidney function, electrolytes, and coagulation profiles. CRP was slightly elevated. Initial diagnosis was pacemaker pocket infection. Echocardiography (Fig.\u0026nbsp;5) and chest X-ray (Fig.\u0026nbsp;6) confirmed that the ventricular lead was positioned at the free wall of the right ventricular outflow tract, where the VT originated.\u003c/p\u003e\u003cp\u003eInterventional Procedure:\u003c/p\u003e\u003cp\u003eDebridement and percutaneous extraction of the pacemaker and leads were performed. The extraction process involved counterclockwise rotation to detach the leads from myocardial tissue (Fig.\u0026nbsp;7). During the procedure,VT occurred but was managed successfully. Post-procedure, the patient received broad-spectrum antibiotics.\u003c/p\u003e\u003cp\u003eOutcome:\u003c/p\u003e\u003cp\u003eThe patient's VT resolved, and no further syncope episodes occurred. Postoperative ECG indicated sinus rhythm with a ventricular rate of 50\u0026ndash;60 bpm (Fig.\u0026nbsp;8). The patient was discharged on postoperative day 7 with no recurrence of infection or arrhythmia at follow-up.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis case report presents a unique scenario of a delayed pacemaker pocket infection occurring three years post-implantation, without positive cultures for any specific pathogen. The absence of pathogen growth in blood and local secretion cultures is particularly notable and warrants discussion. Several factors could contribute to this finding\u003csup\u003e6\u003c/sup\u003e. Firstly, the patient's prior antibiotic treatment at a local hospital before cultures were taken could have suppressed bacterial growth, making it difficult to identify the causative agent. Additionally, the nature of the infection, possibly being subacute or chronic due to the extended period post-implantation, might have led to low bacterial loads that are difficult to culture.\u003c/p\u003e \u003cp\u003eThe patient's profession as a violinist involves repetitive use of the left shoulder, which likely contributed to mechanical wear and erosion at the pacemaker site, increasing the risk of infection. However, the absence of detectable pathogens in the cultures suggests that the inflammatory response could be partially due to non-infectious factors such as mechanical irritation, although the clinical presentation and response to antibiotics indicate an infectious process.\u003c/p\u003e \u003cp\u003eThe unique presentation of VT in this case was associated with the pacemaker lead's positioning in the right ventricular outflow tract, suggesting that the inflammation around the lead, whether infectious or mechanically induced, could exacerbate arrhythmogenicity\u003csup\u003e7\u0026ndash;9\u003c/sup\u003e. Although the patient's ventricular tachycardia (VT) ECG characteristics are not typical, they still suggest a likely origin from the right ventricular outflow tract (RVOT) free wall. The variability in QRS morphology, with lead I showing Rs pattern to rS pattern, leads II, III, aVF showing R pattern, lead V1 showing R pattern, and lead V2 showing rS pattern, may be due to local electrode movement or regional cardiac conduction variations. The termination of VT upon removal of the RVOT free wall electrode further supports this origin despite the atypical ECG presentation\u003csup\u003e10\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe resolution of symptoms following the removal of the device and administration of antibiotics supports the infectious nature of the inflammation, but also highlights the complexity of diagnosing and treating device-related infections when standard cultures fail to identify a pathogen\u003csup\u003e11\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe gradual changes in QRS morphology observed during ventricular tachycardia (VT) in this patient with a right ventricular outflow tract (RVOT) pacemaker lead suggest variable contact between the lead tip and myocardial cells. Despite these morphological changes, the VT frequency remains constant, indicating a stable pacing source likely at the lead tip. These observations are independent of body position changes, reinforcing that the QRS variations are due to local contact variations rather than positional changes of the heart. This phenomenon underscores the significant impact of lead tip positioning on QRS waveform characteristics\u003csup\u003e12\u0026ndash;14\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eRemoving a pacemaker lead three years post-implantation carries a risk of cardiac perforation. However, due to pacemaker pocket and lead infection, removal was necessary. We meticulously prepared for potential complications, including pericardiocentesis and cardiac surgery readiness for emergency open-heart intervention. The extraction of the screw-in lead proceeded smoothly, and the patient experienced no postoperative complications such as pericardial effusion\u003csup\u003e15\u0026ndash;17\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eGiven the lack of positive cultures, the decision to use broad-spectrum antibiotics was prudent and based on the common pathogens associated with pacemaker infections, primarily Staphylococcus species. This approach is justified in cases where clinical signs of infection are evident, but no specific pathogens are identified, as it covers a broad range of potential bacteria.\u003c/p\u003e \u003cp\u003eThe management of the infection through device removal and broad-spectrum antibiotic therapy\u003csup\u003e18, 19\u003c/sup\u003e, in this case, was effective, underlining the importance of a comprehensive approach to suspected infections, especially when empirical treatment is necessary. This case emphasizes the need for careful assessment of occupational factors that may compromise implant sites and highlights the challenges of managing infections when culture results are negative\u003csup\u003e20\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case highlights the link between pacemaker infections and occupational habits, and the arrhythmias related to lead positioning. The patient's violin playing likely caused mechanical stress, leading to infection. Additionally, the ventricular lead's position contributed to arrhythmias. Effective treatment must consider these factors, including broad-spectrum antibiotics and careful lead placement.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by a grant from the Key Science and Technology Project of Ya\u0026apos;an City, with project number 22KJJH0038.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone of the authors has any conflict of interest related to this manuscript.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eEthics Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eConsent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for participation in this case report.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for the publication of this case report, including any associated images.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll relevant data supporting the conclusions of this article are included within the manuscript.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eCode Availability (software application or custom code)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\n\u003cp\u003eClinical trial number: not applicable.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the conception and design of the case report. Yuanguo Chen led the writing of the manuscript and coordinated the case report. Haibo Zhang and Qi Qiao were responsible for clinical data collection and analysis. Lian Ma supervised the study and revised the manuscript critically for intellectual content. All authors have read and approved the final version of the manuscript.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eVoigt A, Shalaby A and Saba S. Rising Rates of Cardiac Rhythm Management Device Infections in the United States: 1996 through 2003. \u003cem\u003eJournal of the American College of Cardiology\u003c/em\u003e. 2006;48:590-591.\u003c/li\u003e\n\u003cli\u003eDa Costa A, Lelièvre H, PhaD, Kirkorian G, Célard M, Chevalier P, Vandenesch Fo, Etienne J and Touboul P. Role of the Preaxillary Flora in Pacemaker Infections. \u003cem\u003eCirculation\u003c/em\u003e. 1998;97:1791-1795.\u003c/li\u003e\n\u003cli\u003eDilsizian V, Budde RPJ, Chen W, Mankad SV, Lindner JR and Nieman K. Best Practices for Imaging Cardiac Device\u0026ndash;Related Infections and Endocarditis. \u003cem\u003eJACC: Cardiovascular Imaging\u003c/em\u003e. 2022;15:891-911.\u003c/li\u003e\n\u003cli\u003eKumar P, Skrabal J, Frasure SE and Pourmand A. Pacemaker lead related myocardial perforation. \u003cem\u003eThe American Journal of Emergency Medicine\u003c/em\u003e. 2022;53:281.e1-281.e3.\u003c/li\u003e\n\u003cli\u003eCurtis AB and Ahmed A. Treatment of Localized Implantable Cardiac Device Pocket Infections. \u003cem\u003eJournal of the American College of Cardiology\u003c/em\u003e. 2023;81:134-135.\u003c/li\u003e\n\u003cli\u003eMela T, McGovern BA, Garan H, Vlahakes GJ, Torchiana DF, Ruskin J and Galvin JM. Long-term infection rates associated with the pectoral versus abdominal approach to cardioverter- defibrillator implants. \u003cem\u003eThe American Journal of Cardiology\u003c/em\u003e. 2001;88:750-753.\u003c/li\u003e\n\u003cli\u003eWisoff BG. Pacemaker-Induced Ventricular Tachycardia. \u003cem\u003eJAMA: The Journal of the American Medical Association\u003c/em\u003e. 1965;192.\u003c/li\u003e\n\u003cli\u003eAtlee JL and Bernstein AD. Runaway Temporary Pacemaker. \u003cem\u003eNew England Journal of Medicine\u003c/em\u003e. 1980;302:1030-1031.\u003c/li\u003e\n\u003cli\u003eBauer A. Imitating ventricular tachycardia. \u003cem\u003eHeart\u003c/em\u003e. 2003;89:1382-a-1382.\u003c/li\u003e\n\u003cli\u003eLandreville JM, Joubert GI, Welisch E, Helleman K and Poonai NP. Atypical Presentation of Right Ventricular Outflow Tract Ventricular Tachycardia. \u003cem\u003eJ Emerg Med\u003c/em\u003e. 2015;49:432-5.\u003c/li\u003e\n\u003cli\u003eDeSimone DC and Sohail MR. Management of bacteremia in patients living with cardiovascular implantable electronic devices. \u003cem\u003eHeart Rhythm\u003c/em\u003e. 2016;13:2247-2252.\u003c/li\u003e\n\u003cli\u003eCastellanos A, Jr. and Lemberg L. Cardiac arrhythmias. 6. Pacemaker arrhythmias and electrocardiographic recognition of pacemaker. \u003cem\u003eCirculation\u003c/em\u003e. 1973;47:1382-91.\u003c/li\u003e\n\u003cli\u003eEscher DJ. Types of pacemakers and their complications. \u003cem\u003eCirculation\u003c/em\u003e. 1973;47:1119-31.\u003c/li\u003e\n\u003cli\u003eErdinler I, Okmen E, Zor U, Zor A, Oguz E, Ketenci B, Akyol A, Aytekin S and Ulufer T. Pacemaker related endocarditis: analysis of seven cases. \u003cem\u003eJpn Heart J\u003c/em\u003e. 2002;43:475-85.\u003c/li\u003e\n\u003cli\u003eZhang J, He L, Xing Q, Zhou X, Li Y, Zhang L, Lu Y, Tuerhong Z, Yang X and Tang B. Evaluation of safety and feasibility of leadless pacemaker implantation following the removal of an infected pacemaker. \u003cem\u003ePacing Clin Electrophysiol\u003c/em\u003e. 2021;44:1711-1716.\u003c/li\u003e\n\u003cli\u003eRuttmann E, Hangler HB, Kilo J, Hofer D, Muller LC, Hintringer F, Muller S, Laufer G and Antretter H. Transvenous pacemaker lead removal is safe and effective even in large vegetations: an analysis of 53 cases of pacemaker lead endocarditis. \u003cem\u003ePacing Clin Electrophysiol\u003c/em\u003e. 2006;29:231-6.\u003c/li\u003e\n\u003cli\u003eFarooqi FM, Talsania S, Hamid S and Rinaldi CA. Extraction of cardiac rhythm devices: indications, techniques and outcomes for the removal of pacemaker and defibrillator leads. \u003cem\u003eInternational Journal of Clinical Practice\u003c/em\u003e. 2010;64:1140-1147.\u003c/li\u003e\n\u003cli\u003eBaddour LM, Epstein AE, Erickson CC, Knight BP, Levison ME, Lockhart PB, Masoudi FA, Okum EJ, Wilson WR, Beerman LB, Bolger AF, Estes NAM, Gewitz M, Newburger JW, Schron EB and Taubert KA. Update on Cardiovascular Implantable Electronic Device Infections and Their Management. \u003cem\u003eCirculation\u003c/em\u003e. 2010;121:458-477.\u003c/li\u003e\n\u003cli\u003eBen Abid F, Al-Saoub H, Howadi F, AlBishawi A and Thapur M. Delayed Pacemaker Generator Pocket and Lead Primary Infection Due to Burkholderia Cepacia. \u003cem\u003eAmerican Journal of Case Reports\u003c/em\u003e. 2017;18:855-858.\u003c/li\u003e\n\u003cli\u003eSohail MR, Uslan DZ, Khan AH, Friedman PA, Hayes DL, Wilson WR, Steckelberg JM, Stoner S and Baddour LM. Management and Outcome of Permanent Pacemaker and Implantable Cardioverter-Defibrillator Infections. \u003cem\u003eJournal of the American College of Cardiology\u003c/em\u003e. 2007;49:1851-1859.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pacemaker infection, Ventricular tachycardia, Lead extraction, Sick sinus syndrome, Occupational habits","lastPublishedDoi":"10.21203/rs.3.rs-5245487/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5245487/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003ePacemaker-related infections are serious complications of cardiac implantable electronic devices (CIEDs)1\u0026ndash;5. This case report aims to describe the occurrence of pacemaker pocket infection and recurrent ventricular tachycardia (VT) in a Chinese amateur violinist with sick sinus syndrome (SSS), and to explore the possible connection between occupational habits and the infection, as well as VT.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA 76-year-old male violinist with a Biotronik Evia DR dual-chamber pacemaker presented with syncope and signs of a pacemaker pocket infection three years after implantation. Despite initial antibiotic treatment, the infection persisted with slightly elevated C-reactive protein (CRP) and negative cultures. The VT originated from the right ventricular outflow tract (RVOT), as confirmed by echocardiography and ECG findings. The infection was treated with debridement and extraction of the pacemaker and leads.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eDebridement and extraction of the pacemaker and leads successfully resolved both the VT and the infection. The VT was likely linked to the infected lead, while the pacemaker infection was attributed to the patient\u0026rsquo;s violin playing, which caused mechanical stress and skin damage at the pacemaker site. Postoperative recovery was uneventful, with no recurrence of infection or arrhythmias at follow-up.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis case highlights the importance of considering a patient\u0026rsquo;s occupational habits when selecting pacemaker pocket sites to prevent infections and complications. In this case, the patient's violin playing likely contributed to mechanical stress at the pacemaker site, leading to infection. Early identification and appropriate management, including device removal, are crucial to prevent further complications.\u003c/p\u003e","manuscriptTitle":"Strains of a Virtuoso: Pacemaker Infection and Ventricular Tachycardia in a Violinist","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-20 07:19:46","doi":"10.21203/rs.3.rs-5245487/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-12T15:46:23+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-12T02:44:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"184053868356095120715432005063771936221","date":"2024-11-12T01:16:57+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-11T07:16:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-10T15:36:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"95401716433122939139971047689763866162","date":"2024-11-10T15:28:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"294712979825628624935299355941045471725","date":"2024-11-08T15:39:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"116177511113172989815198746368545181257","date":"2024-11-06T18:33:57+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-06T18:06:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"82307488149304182214276986836816018747","date":"2024-11-06T18:06:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"296562919278474655503630544189094290202","date":"2024-11-06T17:25:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180587170332839588641944006782516036976","date":"2024-11-06T14:39:56+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-06T14:38:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-22T06:00:03+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-21T10:57:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cardiovascular Disorders","date":"2024-10-11T10:50:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c6f3be75-047f-4459-af93-4eb5434640c7","owner":[],"postedDate":"November 20th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-01-27T16:00:21+00:00","versionOfRecord":{"articleIdentity":"rs-5245487","link":"https://doi.org/10.1186/s12872-025-04495-0","journal":{"identity":"bmc-cardiovascular-disorders","isVorOnly":false,"title":"BMC Cardiovascular Disorders"},"publishedOn":"2025-01-23 15:57:18","publishedOnDateReadable":"January 23rd, 2025"},"versionCreatedAt":"2024-11-20 07:19:46","video":"","vorDoi":"10.1186/s12872-025-04495-0","vorDoiUrl":"https://doi.org/10.1186/s12872-025-04495-0","workflowStages":[]},"version":"v1","identity":"rs-5245487","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5245487","identity":"rs-5245487","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}