Total Extrusion of a Normally Functioning Pacemaker

A 78-year-old man had undergone implantation of an atrial synchronous ventricular inhibited (VDD) pacemaker 2 years before, because of complete atrioventricular block. He had not attended any follow-up visits at our pacemaker clinic since the date of implantation. When his pacemaker battery and lead completely emerged from the implantation site as a consequence of erosion, the patient was admitted to our cardiology outpatient clinic. The pacemaker battery had passed through a large skin defect approximately 5 cm below the pacemaker pocket, and a lead had emerged from another defect near the suture line and tunneled through the skin (Fig. 1). There was erosion around the exit and entry points of the pacing lead, with apparent healing of the tissue beneath. Pacemaker testing revealed that the device's functional values were completely within normal ranges. There was purulent discharge from the eroded areas, and microbiologic cultures were taken from several points around that region. The patient was hospitalized, and an empiric antimicrobial treatment was initiated. A temporary pacemaker lead was inserted, and the infected lead was extracted from the left side. A new battery and lead were implanted in the right side without complication.

Fig. 1 Photograph shows extruded pacemaker and lead, upon the patient's admission to the hospital.

Comment

Pacemaker battery extrusion is a rare late complication of pacemaker implantation. The incidence of skin erosion, the most common late complication, has been estimated to be around 0.8%. Tissue vulnerability in elderly patients, the presence of a thin subcutaneous layer, and erosive action (especially the scratching of an itch) are the important causal factors.¹ Studies have indicated that approximately 32% to 42% of pacemaker infections are associated with erosion of the device pocket.² Nevertheless, the complete extrusion of the pacemaker generator from the subcutaneous pocket is very uncommon and might be due to the patient's depressed level of immunity, poor hygiene, poverty, or cognitive impairment.³ Recommended preventive measures are rigorous rules of asepsis, good local hygiene, and treatment of factors (such as diabetes mellitus) that predispose the patient to infections. In elderly patients especially, the skin should be inspected carefully at the site of the intended pocket, and a deep pocket, instead of just a pocket under the skin, should be considered in order to prevent this rare complication.