Reimplantation of a Pacemaker into a Subpectoral Pocket Via the Lateral Approach in Collaboration with Plastic Surgeons

Abstract

An 86-year-old woman had a pacemaker implanted into a subfascial pocket. After four months, the generator became exposed, and the pacemaker was removed. She exhibited a lack of prepectoral tissue. We therefore performed reimplantation in collaboration with plastic surgeons. We placed the leads via the extrathoracic subclavian venous approach, and plastic surgeons created a subpectoral pocket from the low lateral side of the pectoralis major muscle. General cardiologists rarely create subpectoral pockets and they are unable to implant leadless pacemakers at their hospital due to lack of sufficient skill. Our case showed that creating a subpectoral pocket in collaboration with plastic surgeons is quick and safe.

Introduction

Recently, a steady increase in the number of implantations of cardiac implantable electronic devices (CIEDs) has been noted. In particular, implantable cardioverter defibrillators (ICDs) and cardiac resynchronization therapy defibrillators have become common therapy. Cardiologists typically implant CIEDs into a subcutaneous pocket because it is generally safe, and the procedure time is shorter than that required for a subpectoral pocket (1). As society ages, however, we may need to implant CIEDs in thin elderly patients. In such cases, making a subfascial pocket is effective (2).

Furthermore, the incidence of infection of CIEDs implanted in elderly patients is increasing, and these patients subsequently require CIED reimplantation. In cases of the reimplantation of pacemaker, a leadless pacemaker may be selected, given its advantages against infection. However, the safe operation of a leadless pacemaker requires substantial experience, and many general cardiologists are thus unable to implant it at their hospital. Therefore, cardiologists need to consider other approaches for the implantation or reimplantation of CIEDs.

In the present case, we decided to perform the subpectoral implantation of a pacemaker. Implantation of CIEDs into a subpectoral pocket is relatively rare, and cardiologists generally do not have much experience in this regard. One drawback to deep dissection in the pocket is the narrow field of view. Furthermore, creating the subpectoral pocket using the same method as that for creating a subcutaneous or subfascial pocket might result in complications such as bleeding and hematoma (3). We believe that the lateral approach to creating the subpectoral pocket solves this issue, and creating it in collaboration with plastic surgeons does not require special skill for general cardiologists.

Plastic surgeons often perform implantations under the pectoralis major muscle for the reconstruction of breast tissue. Compared with cardiologists, they have more experience and knowledge concerning the creation of a subpectoral pocket while avoiding complications.

Case Report

An 86-year-old woman was hospitalized due to advanced atrioventricular block. She was petite (height: 137 cm, weight: 31.0 kg), lacked fatty tissue on both pectoralis major muscles, and took steroids for polymyalgia rheumatica (predonisolone, 5 mg per day). We carefully implanted a permanent pacemaker into her left subfascial pocket. Unfortunately, we were unable to suture only one subcutaneous layer. While no pacemaker pocket erosion was observed for three months after surgery, at four months, the pacemaker generator became exposed through the left subclavian incision (Fig. 1A). Although the pacemaker generator was infected, her white blood cells and C-reactive protein levels did not increase, and blood culture was negative.

Figure 1.

Images of the surgical scar. A: Exposure of the generator at the left surgical scar. B: The right surgical scar after reimplantation in the subpectoral pocket. C: The right surgical scar after one year.

We removed the entire pacemaker system. Slight adhesion of the leads was observed, and we extracted the leads manually under local anesthesia. We asked plastic surgeons to assist in the debridement of the necrotic tissue. The patient required early reimplantation of the new pacemaker. In addition, there was little fatty tissue on her right pectoralis major muscle.

We performed the implantation in collaboration with plastic surgeons two weeks after removing the pacemaker system. Under local anesthesia, we made an incision line on her right subclavian skin of approximately 1 cm and divided the subcutaneous tissue and pectoralis major muscle (Fig. 2A). We punctured her right subclavian vein from the incision line via the extrathoracic subclavian approach. The leads were placed at the right ventricular apex and right atrial appendage. The leads were fixed to the pectoralis major muscle using a silk thread (Fig. 2B). Next, under local anesthesia, plastic surgeons created a subpectoral pocket from the low lateral side of the pectoralis major muscle (Fig. 2C) in about 10-15 minutes without bleeding. The generator and leads were connected under the muscle and placed in the subpectoral pocket. Finally, we sutured the two scars (Fig. 1B). She left our hospital after one week without any complications such as bleeding, hematoma, or infection(Fig. 3). She returned to our hospital after one year for a follow-up visit, and the scar was clear without skin erosion (Fig. 1C).

Figure 2.

A: We made an incision line of approximately 1 cm on the subclavian skin and divided the subcutaneous tissue and muscle. B: We punctured the subclavian vein from the incision line via the extrathoracic subclavian approach. C: Plastic surgeons created the subpectoral pocket from the lower lateral side of the pectoralis major muscle.

Figure 3.

Chest X-ray obtained one week after reimplantation.

Discussion

Subpectoral implantation is a well-recognized technique that has been available since the 1960s. The merits of subpectoral implantation were highlighted anew in commentary published approximately two decades ago (4). However, many general cardiologists lack sufficient knowledge and experience to create a subpectoral pocket.

As the lateral approach for creating the subpectoral pocket is rarely reported (5,6), this approach to implantation is unfortunately not recognized by many general cardiologists; however some arrhythmia cardiologists are aware of it. When creating a subpectoral pocket, cardiologists may create a subpectoral pocket from the usual incisional line of the subclavian skin toward the inferior direction. However, with this approach, bleeding can occur due to damage to the pectoris major muscle, and the narrow field of view makes it difficult to stop this bleeding. The layer of the low lateral side of the pectoralis major muscle is sparser than the anterior side of this muscle. Therefore, dividing the layer from the low lateral side of the pectoris major muscle is relatively easy and yields a wider field of view, while minimizing bleeding and hematoma. In the present case, bleeding and hematoma did not occur. Plastic surgeons often perform implantations under the pectoralis major muscle using this lateral approach during breast reconstruction. We believe that collaborating with plastic surgeons to create a pocket for CIEDs under the pectoralis major muscle is safe and quick for patients.

General anesthesia is typically used in reports of the lateral approach (5,6). Furthermore, patients typically require a large subpectoral pocket for implantable cardioverter defibrillator implantation. Our patient was an elderly woman, and the pacemaker generator required a small subpectoral pocket. Pneumonia and delirium often develop when general anesthesia is administered to elderly patients. We explained the risks and benefits of each anesthesia approach to the patient, and she ultimately selected local anesthesia.

Recently, the number of implantations of leadless pacemakers has markedly increased, given its many advantages against infection. Successful lead extraction and leadless pacemaker implantation reportedly remained free from re-infection in patients who had suffered from traditional pacemaker infection (7). The implantation of a leadless pacemaker is reportedly safe (8), even in Japanese patients (9). In general, the leadless pacemaker is the first choice for reimplantation in patients with pacemaker infection who are suitable for a VVI pacemaker. However, an advanced age (>75 years old), female gender, low body mass index (<20 kg/m²), and history of chronic obstructive pulmonary disease are risk factors of cardiac effusion or perforation events with the implantation of a leadless pacemaker (10). The present patient had multiple risk factors, including an advanced age, female gender and low body mass index (16.5 kg/m²). She was therefore not suitable for the implantation of a leadless pacemaker.

However, there are some disadvantage associated with this approach. For one, this approach takes more time and requires more local anesthesia than the conventional method. It is also difficult to detect generator infection in the subpectoral pocket. In addition, the generator exchange via this approach of implantation should be performed in collaboration with plastic surgeons. While complications are rare when creating a subpectoral pocket using the lateral approach, injury to the perforating branches of the internal thoracic artery or lateral thoracic nerve might occur if the subpectoral pocket is created extremely lateral or inside of the chest. Thin elderly patients deemed too risky for leadless pacemaker implantation may benefit from this approach.

Performing implantation in the subpectoral pocket in collaboration with plastic surgeons is a safe and easy approach for general cardiologists. We believe that cardiologists should consider the lateral approach with the subpectoral pocket for the implantation or reimplantation of CIEDs in small-frame elderly patients.

The authors state that they have no Conflict of Interest (COI).