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Eroded Pacemaker in an Elderly Patient

      To the Editor:
      An 84-year-old man with severe ischemic cardiomyopathy and history of congestive heart failure was transferred to our hospital for biventricular implantable cardioverter defibrillator pocket erosion. He had originally undergone dual-chamber pacemaker implantation for intermittent complete atrioventricular block in 2000. He then developed worsening heart failure symptoms in the setting of declining left ventricular (LV) systolic function, and the device was upgraded to a biventricular system in 2006. There was initial improvement that disappeared due to LV lead dislodgement. Attempted LV lead revision in July 2007 was not successful. Two weeks later he underwent epicardial LV lead placement via mini-thoracotomy. Postoperatively he had ongoing discomfort at the wound, and in December 2007 he developed worsening redness and discomfort over the device.
      Unfortunately, he did not seek medical attention until he noticed the pacemaker was eroding through his skin (Figure 1, Figure 2). On presentation he was afebrile without other complaints.
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      Figure 1Left lateral view of the site upon presentation. Photo taken prior to extraction and debridement of the eroded pacemaker.
      Wound and blood cultures did not grow an organism, but intravenous vancomycin was initiated at the outside hospital for presumed infection. The patient was transferred to our hospital on his 12th day of antibiotics. He underwent successful total system extraction. Exposure of the pocket revealed purulent drainage beneath the device. The leads were entirely removed using laser lead extraction sheathes.
      The pocket was debrided down to normal tissue, and the wound was packed and left open. By holding beta-blockers, temporary pacing was avoided. Wound healing progressed nicely, and a wound vacuum was placed. After 7 days of continued antibiotics and negative cultures, a new biventricular implantable cardioverter defibrillator was implanted successfully on the right side. The patient was discharged home the next day with home intravenous infusion of antibiotics for 3 more weeks. The wound vacuum was removed after 3 weeks.
      Risk factors for implanted cardiac device infection include multiple device revisions, early re-interventions, temporary pacing wires at time of implantation, and lack of antibiotic prophylaxis at the time of the procedure. Removal of the device, along with all leads and infected tissue, is necessary for clearance of the infection. Separating the explant procedure from the reimplant procedure is ideal, and when the patient is pacemaker dependent, pacing becomes necessary. Redness and swelling over the device site inarguably indicates infection and frequently leads to erosion if not managed appropriately. Erosion of the device can result in loss of pacing or ineffective defibrillation.