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J Thorac Cardiovasc Surg 1994;107:1164-1165
© 1994 Mosby, Inc.

LETTERS TO THE EDITOR

Removal of infected transvenous pacemakers

Victor Aldrete, MD, FRCS(C), FACS, George E. Miller, MD, FRCS(C), FACS

Department of Cardiovascular Surgery and Medicine
Holy Cross Hospital
Calgary, Alberta, Canada

To the Editor:

I read with interest the exhaustive and informative report of Brodman and coworkers Go 1 regarding the treatment of infected permanent pacemaker hardware. The necessity of complete removal of all foreign materials is of paramount importance in cases of systemic infection if satisfactory results are to be achieved.

From January 1980 to March 1992 in our institution, we have performed 1067 implantations of permanent pacemakers; 822 were new implantations and 245 were generator replacements. Two patients have required thoracotomy for removal of infected pacemakers, a prevalence of 0.19%. In one of these patients, full cardiopulmonary bypass was used; in the second patient, an inflow occlusion technique was necessary. We would like to report the case in which the inflow occlusion technique was used because no other satisfactory alternative was feasible.

A 75-year-old woman was referred to our service for the implantation of a permanent transvenous pacemaker for a 2-week history of syncopal episodes caused by intermittent heart block and prolonged periods of bradycardia with heart rates as slow as 20 beats/min. A transvenous VVI permanent pacemaker was inserted through the left cephalic vein and the pulse generator was implanted subcutaneously in the left pectoralis major area. After satisfactory function of the pacemaker was ensured, the patient was discharged home 2 days after the operation, only to return 10 days later in poor general condition with a left lower lobe pneumonia. Further investigations demonstrated a morbidly obese, gouty, arthritic woman with blood cultures that grew methicillin-sensitive Staphylococcus aureus. Culture of a localized phlebitis in the dorsum of the right hand also grew S. aureus. This appeared to be the initial infection site, which must have arisen during the first admission with an infection at the intravenous line site.

The patient was treated with appropriate intravenous antibiotics but continued to have recurrent pneumonitis because of embolization of infected material to the lungs. The patient remained in a septic condition with progressive thrombocytopenia. Echocardiography demonstrated a large, pedunculated vegetation seated at the junction of the tricuspid valve and the permanent venous lead (Fig. 1). The vegetation was such that cardiopulmonary bypass with routine cardiac cannulation appeared too risky because of possible dislodgment of the vegetation, aside from persistent sepsis and thrombocytopenia in an unwell, elderly, obese patient. The removal of the infected hardware was mandatory, but even more important was the need for emergency removal of the large, unstable vegetation.



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  		Fig. 1. Echocardiographic view of large, pedunculated vegetation seated at the junction of the tricuspid valve and the permanent venous lead.

 
We operated on the patient with cardiopulmonary bypass standby. The approach was made through a standard median sternotomy. No anticoagulation was used. With the use of inflow occlusion, the right atrium was opened, the vegetation and pacer lead were removed from the right ventricle and atrium, and the lead was divided at the junction of the superior vena cava and right atrium. A second look was taken to ensure complete removal of the vegetation from the tricuspid valve. To this purpose, two periods of inflow occlusion of 120 and 70 seconds were used. The patient's hemodynamic parameters recovered quickly on both occasions. A new pulse generator was implanted in the left subcostal region, connected to an epicardial permanent pacing lead. The remainder of the transvenous pacing lead and pulse generator were removed simultaneously through the pulse generator site after closure of the median sternotomy. The patient was maintained on intravenous antibiotics for 3 more weeks, with continued improvement and resolution of the sepsis and thrombocytopenia. She was discharged in good condition, with a prescription for oral antibiotics for a further 2 weeks, for follow-up as an outpatient. The echocardiographic identification of the intracardiac vegetation prevented us from blind removal of the infected pacer lead and also led us to use inflow occlusion, thus avoiding the likely embolization of a large vegetation that could possibly have produced a fatal pulmonary embolus.

When a systemic infection has been identified in the presence of a permanent pacemaker, echocardiography should be a routine investigation to rule out the presence of possible intracardiac vegetations. The use of the inflow occlusion technique should be kept in mind when situations like this arise. This technique can prevent the complications of using cardiopulmonary bypass in systemic infections and in high-risk patients who seem able to tolerate an operation but less able to tolerate cardiopulmonary bypass.

References

  1. Brodman R, Frame R, Andrews C, Furman S. Removal of infected transvenous leads requiring cardiopulmonary bypass or inflow occlusion. J THORAC CARDIOVASC SURG 1992;103:649-54.[Abstract]



This article has been cited by other articles:


Home page
 Ann. Thorac. Surg.Home page
J.-P. Chang, M.-C. Chen, G. B.-F. Guo, and C.-L. Kao
Less-Invasive Surgical Extraction of Problematic or Infected Permanent Transvenous Pacemaker System
Ann. Thorac. Surg., April 1, 2005; 79(4): 1250 - 1254.
[Abstract] [Full Text] [PDF]

This Article
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