Ann Thorac Surg 1997;63:1466-1467
© 1997 The Society of Thoracic Surgeons
Case Report
Cardiac Pacemaker Dysfunction in Children After Thoracic Drainage Catheter Manipulation
Kevin W. Lobdell, MD,
Henry L. Walters, III, MD,
Claudia Hudson, BSN,
Mehdi Hakimi, MD
Department of Cardiovascular Surgery, Children's Hospital of Michigan, Detroit, Michigan
Accepted for publication December 6, 1996.
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Abstract
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Two children underwent placement of permanent, epicardial-lead, dual-chamber, unipolar pacemaker systems for complete heart block. Postoperatively, both patients demonstrated subcutaneous emphysema-in the area of their pulse generators-temporally related to thoracic catheter manipulation. Acutely, each situation was managed with manual compression of the pulse generator, ascertaining appropriate pacemaker sensing and pacing. Maintenance of compression with pressure dressings, vigilant observation/monitoring, and education of the care givers resulted in satisfactory pacemaker function without invasive intervention.
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Introduction
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Congenitally corrected transposition of the great arteries and naturally acquired complete heart block are commonly associated [1]. Two children with congenitally corrected transposition of the great arteries operated on at the Children's Hospital of Michigan during the last year had permanent, dual-chamber, epicardial, unipolar pacemaker systems (PPSs) placed for complete heart block and subsequent development of subcutaneous emphysema in the pulse generator pocket.
Patient 1, a 2-year-old boy with congenitally corrected transposition of the great arteries, underwent relief of left ventricular outflow tract obstruction via median sternotomy on cardiopulmonary bypass and placement of PPS after the termination of bypass. The epicardial leads were tunneled through the rectus abdominis and connected to the pulse generator, which was placed in the subcutaneous space of the anterior abdominal wall (in the left upper quadrant). Two mediastinal tubes and a single left pleural tube were placed in a routine manner to evacuate air and fluid during the postoperative period. This patient's postoperative course was uneventful until mediastinal and pleural tube removal. Immediately after removal of the thoracic drainage catheters, the patient was noted to have pacemaker-generated impulses on the electrocardiogram, which did not correlate with the patient's pulse (arterial pressure monitor or physical examination), suggesting PPS malfunction. Temporary pacing wires, placed at the time of operation, were used to pace the heart while a physical examination ensued and a chest radiograph was obtained. Chest radiography (Figs 1, 2
) corroborated the sign of crepitus, demonstrating considerable subcutaneous emphysema in the upper abdominal wall (the area of pacemaker generator placement), while simultaneously exhibiting apparently adequate position of the permanent epicardial pacemaker leads. Manual compression in the area of the permanent pacemaker generator reestablished appropriate sensing and pacing. A pressure dressing was fashioned and applied over the permanent pacemaker generator site. This child was vigilantly monitored with continuous electrocardiography, serial physical examinations, and intermittent interrogation of the PPS. The temporary pacemaker system was used as a "backup," and the pressure dressings were used throughout the remainder of the patient's hospital course. This child was discharged from the hospital on the fifth postoperative day with a pressure dressing and a functional PPS. The subcutaneous emphysema had largely resolved by the time of discharge and was followed up until complete resolution.
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Fig 1. . (Patient 1.) Posteroanterior radiograph demonstrating chest and abdominal wall subcutaneous emphysema.
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Fig 2. . (Patient 1.) Lateral radiograph demonstrating subcutaneous emphysema in the area of the pulse generator.
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Patient 2, a 3-year-old boy with congenitally corrected transposition of the great arteries, underwent a left anterior thoracotomy to expose the heart and place permanent, epicardial, atrial and ventricular pacemaker leads. These pacemaker leads were tunneled through the chest wall and connected to a pulse generator in the left upper quadrant of the anterior abdominal wall. When the patient awakened from general anesthesia, he dislodged the pleural tube that was placed to drain the left pleural space. Crepitus was noted on the patient's chest and abdominal wall. Direct pressure over the pulse generator maintained ground, and appropriate sensing and pacing persisted. Plain radiography delineated subcutaneous emphysema around the pulse generator and guided the repositioning of the thoracic catheter (similar to patient 1 the pacemaker lead positions appeared appropriate and this patient was treated with pressure dressings over the pacemaker generator site, continuous electrocardiography, and serial physical examinations). The thoracic catheter was removed uneventfully on the third postoperative day, and the patient was discharged on the fourth postoperative day. The pressure dressings were used until resolution of the subcutaneous emphysema.
Patients 1 and 2 had outpatient interrogation of their PPS, demonstrating excellent function. Education of the care givers (physicians, nurses, and parents) allowed these children to be managed safely with a conservative, noninvasive approach.
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Comment
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The cases we present are similar and represent an unusual cause of cardiac pacemaker dysfunction in young children. Handy and colleagues [2] described a patient with pacemaker dysfunction related to "pocket emphysema" related to dissection of intrapericardial air. Similarly, others have reported PPS dysfunction related to emphysema in the pulse generator pocket [3–6]. The unifying principle in each of the reported cases of unipolar pacemaker dysfunction related to subcutaneous emphysema was the loss of contact between the anodal ground plate of the pulse generator and the patient's tissue. In each of our cases, a child had manipulation of a thoracic drainage catheter, through which air was introduced into the thorax after the placement of a PPS. Subsequent to thoracic catheter manipulation, air dissected from the thoracic cavity into the subcutaneous space. Crepitus was readily apparent in each case, and the subcutaneous emphysema was clearly depicted with plain radiographs. The asthenic nature of the children described may have contributed to the ease of air dissecting into the subcutaneous pulse generator pockets. Adequate tunneling of a thoracic drainage catheter, rapid removal of the catheter, and manual pressure along the catheter tract, and pursestring sutures at the skin wound (tied upon removal of the catheter) should minimize the potential for introducing air into the thorax, particularly in the pediatric population. A conservative, noninvasive method of management and appropriate education allowed these children to fully recover and maintain excellent long-term pacemaker function. Avoidance of invasive measures avoided the theoretical risk of infecting the permanent system as well as the potential for patient discomfort and expenditure of additional resources. This unusual presentation of unipolar pacemaker failure in children after thoracic catheter manipulation demonstrates an acute problem, successfully diagnosed and treated reliably with ordinary means.
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Footnotes
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Address reprint requests to Dr Lobdell, Department of Cardiovascular Surgery, Children's Hospital of Michigan, 3901 Beaubien Blvd, Detroit, MI 48201.
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References
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- Kirklin JW, Barratt-Boyes BG. Congenitally corrected transpositin of the great arteries. In: Kirklin JW, Barratt-Boyes BG, eds. Cardiac surgery. Second ed. New York: Churchill Livingstone, 1993:1513–5.
- Handy JR, Gillette PC, Sade RM. Pacemaker failure due to pocket emphysema. Ann Thorac Surg 1994;57:1331–3.[Abstract]
- Smith SA, Weissberg PL, Tan LB. Permanent pacemaker failure due to surgical emphysema. Br Heart J 1985;54:220–1.[Abstract/Free Full Text]
- Hearn SF, Maloney JD. Pacemaker system failure secondary to air entrapment within the pulse generator pocket. A complication of subclavian venipuncture for lead placement. Chest 1982;82:651–4.[Abstract/Free Full Text]
- Giroud D, Goy JJ. Pacemaker malfunction due to subcutaneous emphysema. Int J Cardiol 1990;26:234–6.[Medline]
- Santomauro M, Ferraro S, Maddalena G, et al. Pacemaker malfunction due to subcutaneous emphysema-a case report. Angiology 1992;43:873–6.
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Abstract
Introduction
