Ann Thorac Surg 1998;66:550-551
© 1998 The Society of Thoracic Surgeons
Case Reports
Delayed presentation of foreign body reaction secondary to retained pacing wires
Darryl A. Chung, FRCSa,
Edward E.J. Smith, FRCSa
a Department of Surgery, St. George’s Hospital, London, England, United Kingdom
Accepted for publication February 18, 1998.
Address reprint requests to Mr Chung, Department of Thoracic Surgery, Norfolk and Norwich Hospital, Norwich NR1 3SR, England
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Abstract
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Temporary pacing wires are often left behind, assumed not to cause problems. We present 2 cases of delayed presentation of anterior mediastinal foreign body reaction secondary to retained pacing wires after coronary operations performed more than 5 years previously.
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Introduction
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Two patients operated on by us presented with persistent chest wall sinuses secondary to pacing wires (Flexon 2589-63; Sherwood, Davis and Geck, Hampshire, UK) more than 5 years after having had coronary artery operations.
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Case reports
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Patient 1
A 59-year-old man had double coronary bypass grafts with routine placement of one right ventricular and two right atrial pacing wires. His postoperative recovery was uneventful. Six years later, an abscess developed in the lower third of his sternotomy incision. This was opened and debrided and the lowest of the sternal wires was removed. The wound healed, but a midsternal swelling and a right subcostal sinus then developed.
Chest radiographs showed the pacing wires but no other abnormality. However, a computed tomographic scan (Fig 1) revealed an ill-defined area of soft tissue behind the sternum extending into the superior mediastinum containing wire remnants. At subsequent operation, the sinus was opened and an old atrial pacing wire was removed. A second pacing wire and the remaining sternal wires were removed by separate incisions. The wounds were left to heal by secondary intention. At follow-up, the patient had made a full recovery.
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Fig 1. Computed chest tomogram with mediastinal view showing pacing wire and soft tissue mass anterior to pulmonary trunk.
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Patient 2
A 64-year-old woman had quadruple coronary bypass grafts 7 years previously, with routine placement of one right ventricular and two right atrial pacing wires. Apart from an episode of atrial fibrillation and a mild lower respiratory tract infection, her postoperative recovery was uneventful.
Five years later, an abscess developed in the lower third of her sternotomy incision, but she was otherwise well. This was incised and drained and a sternal wire was removed. A discharging sinus subsequently developed, which did not resolve despite various antibiotics. One year later, the remaining sternal wires were removed and the wound was debrided. With persistence of the sinus, a computed tomographic scan was performed, which revealed a retrosternal collection associated with a retained pacing wire. The pacing wire was removed upon exploration and curettage of the sinus, and a serosanguineous collection was drained, leaving healthy-looking tissue. Histologic examination showed merely chronic inflammation. A scanty growth of coagulase-negative Staphylococcus aureus was cultured. The wound healed well without further problems.
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Comment
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The placement of temporary epicardial pacing wires in cardiac surgery is commonly practiced to cope with early postoperative bradyrhythmias or asystolic episodes. These wires are normally removed by simple external traction after a few days when it seems certain that the normal cardiac rhythm is reestablished or, if necessary, a permanent pacemaker has been inserted. Not infrequently, however, these wires are cut at the skin surface if removal seems difficult.
Infection associated with temporary epicardial pacing wires is a recognized early complication. However, the late presentation of our 2 previously well patients is unusual. Wound cultures were negative in 1 of our patients, and the scanty growth of Staphylococcus aureus from the other may represent mere colonization rather than true infection. Indeed, a previously published study of routinely cultured epicardial pacing wires did not show any clinical significance of this isolate [1]. It is plausible that both instances reflect an indolent foreign body reaction, a noted cause of chronic inflammation [2]. A similar case related to silk sensitivity has been reported [3].
Although a major complication rate of 0.4% has been quoted for placement and removal of temporary epicardial pacing wires [4], foreign body reaction as a late complication of retained pacing wires has only rarely been noted [5]. However, temporary pacing wires must be considered capable of providing a focus for infection or inciting a latent reaction of rejection by the body.
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References
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- Hastings J.C., III, Robicsek F. Clinical significance of epicardial pacing wire cultures. J Thorac Cardiovasc Surg 1993;105:165-167.[Abstract]
- Cotran R.S., Kumar V., Robbins S.L. Robbins pathologic basis of disease, 5th ed. Philadelphia: Saunders, 1994:51-92.
- Roe B.B. Calcified postoperative epicardial granuloma. Ann Thorac Surg 1975;19:472-473.[Abstract/Free Full Text]
- Del Nido P., Goldman B.S. Temporary epicardial pacing after open heart surgery: complications and prevention. J Cardiac Surg 1989;4:99-103.[Medline]
- Gentry W.H., Hassan A.A. Complications of retained epicardial pacing wires: an unusual bronchial foreign body. Ann Thorac Surg 1993;56:1391-1393.[Medline]
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Abstract
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