Europace Advance Access originally published online on June 22, 2008
Europace 2008 10(9):1122-1123; doi:10.1093/europace/eun168
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org
CASE REPORTS
Pocket infection related to retained products of pacing
Shoaib Hamid1,*,
Nikhil Patel2 and
Cliff Bucknall1
1 Cardiothoracic Department, St Thomas' Hospital, London SE1 7EH, UK;
2 Department of Cardiology, Eastbourne District General Hospital, Eastbourne, BN21 2UD, UK
Manuscript submitted 7 April 2008. Accepted after revision 23 May 2008.
* Corresponding author. Tel: +44 207 1887335; fax: +44 207 1882435. E-mail address: shoaibhamid{at}hotmail.com
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Abstract
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With the advent of increasing number of implants and more complex
pacing systems, referrals for explantations are likely to increase.
These procedures have their attendant peri-procedural risks.
We report a delayed complication of a system explant, which
could have been avoided, and suggest changes in clinical practice
that may prevent similar cases.
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Introduction
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Device therapy is being increasingly utilized in the management
of arrhythmias and heart failure. This has been associated with
an increased demand for lead extractions with its associated
risks. This case report illustrates a co-morbidity that could
have been avoided, with suggestions to prevent such complications
occurring in the future.
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Case report
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A 61-year-old man was referred to our institution towards the
end of February 2007 for explantation of an implantable defibrillator
after a 1-week history of a painful pocket. He had a history
of ischaemic heart disease, and in April 2000, he underwent
implantation of an implantable defibrillator (Medtronic Gem
III, Medtronic Inc., Minneapolis, MN, USA) after being resuscitated
from a cardiac arrest secondary to ventricular fibrillation.
In 2002, he underwent placement of a ventricular pace/sense
lead as the threshold had become unacceptably high on the original
shock lead. In 2007, the wound was intact but the pocket appeared
indurated and was tender. His inflammatory markers were not
raised and blood cultures were negative. Transthoracic echocardiography
did not suggest the presence of obvious infective vegetations.
The explant was performed in March 2007 in the cardiac catheter suite. Upon opening the pocket, pus was found around the device. This was explanted, and all three active fixation leads, an atrial lead, a right ventricular shock, and pace/sense lead, were removed intact along with their sleeves utilizing locking stylets and manual traction. The pocket was explored, cleaned with iodine, and the wound closed with interrupted silk. A chest X-ray post-procedure did not demonstrate any remnants of the leads.
Klebsiella was cultured from the explanted leads, and a course of ciprofloxacin was administered in accordance with microbiological sensitivities. After a further week of antibiotic therapy, this gentleman underwent re-implantation of a dual-chamber defibrillator (Guidant Contak, Guidant Corp., St Paul, MN, USA) via the right-sided approach.
By the end of August 2007 after having received two courses of antibiotics, he represented with what appeared to be a wound infection of the original left-sided explant site. The wound on right side had healed satisfactorily. He was apyrexial and his inflammatory markers were within the normal range. The pocket was X-rayed again but no radio-opaque material was identified (Figure 1). Upon re-opening, pus was present inside the pocket, and upon further re-exploration, a lead cap was found and removed (Figure 2). The pocket was cleaned and the wound was closed. He was given a 48 h course of intravenous vancomycin. On review after 2 weeks, the wound had healed satisfactorily.
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Discussion
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The retained lead cap, placed on the pace/sense part of the
shock lead during the lead revision in 2002, acted as a continuing
source of post-explantation infection, necessitating re-exploration
of the wound.
This case illustrates numerous points of vital importance:
- The need for clear documentation when lead revisions are performed, particularly regarding the removal of pacing lead anchoring sleeves and the use of plastic lead caps. The fact that the original pace/sense lead had been capped had not been documented.
- Post-procedural radiography was not helpful in confirming the removal of all pacing materials.
- Removal of the pacing lead does not guarantee the removal of all lead-infected materials.
With increasing numbers of implants and more complex pacing
systems, the number of explantations is also likely to increase
along with the risks involved with these procedures.
1
We advocate
that radio-opaque markers should be integrated into lead anchoring
sleeves and caps by device manufacturers. In addition, we suggest
that documentation of the use of any adjuvant materials utilized
in pacing system revisions, such as lead caps, should be a mandatory
requirement on the patient's pacemaker cards as well as documentation
in the patients' hospital records. These measures would facilitate
the removal of all the materials with device explantations and
prevent any morbidity associated with the retained products
of pacing.
Conflict of interest: none declared.
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Reference
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[1] Kennergren C, Bucknall CA, Butter C, Charles R, Fuhrer J, Grosfeld M, et al. PLESSE investigators group. Laser-assisted lead extraction: the European experience. Europace (2007) 9:651–6.
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Abstract
Introduction
