Ann Thorac Surg 1999;67:1782-1783
© 1999 The Society of Thoracic Surgeons
Case Reports
Fibrous ball: a new manifestation of chronic defibrillator and pacemaker infection
G. Hossein Almassi, MDa,
Charles E. Edmiston, Jr, PhDb,
Gordon N. Olinger, MDa
a Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
b Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
Accepted for publication November 6, 1998.
Address reprint requests to Dr Almassi, Division of Cardiothoracic Surgery, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226
e-mail: galmassi{at}mcw.edu
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Abstract
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Two patients with unusual manifestation of long-term infection of implantable cardioverter defibrillator and pacemaker were examined. Complete explanation of the defibrillator and pacemaker was done in both patients. New devices were subsequently implanted.
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Introduction
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Implantable cardioverter defibrillators (ICD) and cardiac pacemakers are major lifesaving devices. Infection associated with these implants has been well described [1–3]. We treated two patients with exuberant fibrous reaction as the sole manifestation of chronic infection.
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Patient 1
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Several months after an uncomplicated ICD generator replacement in 1994, a 54-year-old man with severe dilated cardiomyopathy noticed gradual painless swelling of the generator site along with skin discoloration. Because there was no evidence of an infectious process, this was attributed to a possible allergic reaction to the titanium casing of the ICD generator. In 1997 an attempt to aspirate material from the generator pocket was negative. Aspirates of injected saline remained culture negative and the patient was referred to the cardiothoracic service.
The patient denied any discomfort, fever, or chills. Examination disclosed a large painless mass over the ICD generator with doughly consistency and skin discoloration to a brown and purple color (Fig 1). A computed tomographic scan of the chest showed thickening and a large volume of questionable fluid under the epicardial defibrillating patch leads. At operation the findings included a thick fibrous ball encasing the ICD generator with no fluid in the pocket. Similar thick fibrous tissue encased the ICD patch electrodes. The fibrous ball around the ICD generator as well as the patch leads was excised in its entirety (Fig 2). Cultures of the explanted ICD leads submitted for sonication grew pure colonies of Staphylococcus epidermidis. Swabs of the explanted specimens were culture negative. Two weeks later a transvenous ICD system was implanted through the left subclavian vein with subpectoral placement of the generator.
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Fig 1. Extreme swelling and skin discoloration of implantable cardioverter defibrillator generator site in patient 1.
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Histopathologic examination of the fibrous material did not reveal any microorganisms. After a 6-week course of intravenous vancomycin therapy, the patient was switched to oral antibiotics. He is doing well 1 year later with no evidence of recurrence. The skin discoloration of the abdominal wall has faded away.
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Patient 2
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A 77-year-old man had underwent an uncomplicated transvenous pacemaker implantation via a subclavian vein approach. Eight months later he noticed swelling and painful sensitivity of his skin over the pacemaker generator. There was no evidence of fluid in the pacemaker pocket and the patient denied having fever or chills. Again, the presumptive diagnosis was chronic pacemaker infection and the entire device was explanted using the commercially available lead extraction system (Cook Pacemaker Corporation, Leechburg, PA). Operative findings included a thick fibrous capsule surrounding the device without evidence of purulent material in the pocket. Sonication of the explanted leads grew colonies of S epidermidis. The patient was treated with a 6-week course of intravenous vancomycin. Two weeks after explantation of the old pacemaker, a new device was implanted via the right subclavian vein and the generator placed under the pectoralis muscle.
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Comment
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Late-onset infections of biomedical devices are frequently caused by S epidermidis and typically present as occult and are rarely associated with the cardinal signs of infection. However, these infections are usually associated with purulent fluid accumulation within the subcutaneous generator pocket or underneath the epicardial patch lead and can be detected by computed tomographic scan [1].
We previously reported the recovery of S epidermidis from infected ICD generator pockets [1]. Adherence of slime-producing strains of S epidermidis to a biomedical device is frequently tenacious, and sonication of the device is often required to disperse the vegetative growth and enhance cultural recovery of the organism [4].
The amount of fibrous material associated with the implanted devices in these two patients was excessive and highly unusual. The role of staphylococcal contamination in exacerbating the development of this fibrous capsule formation is unknown. However, S epidermidis has been suggested to be linked to unilateral capsular contraction around breast implants [5]. The other unusual finding was the discoloration of skin in the first patient and its gradual resolution after removal of the ICD.
We believe that these infections are primarily device based and not tissue based and, therefore, removal of the device eliminates the source of the infection, rendering wide tissue debridement unnecessary [6]. Excision of both the fibrous capsule and the bioimplant will eliminate the source of infection, allowing timely replacement of the device. We prefer to implant the device in a submuscular pocket as this appears to be associated with a low infection rate (unpublished data).
Chronic infection of ICD implant and pacemaker with S epidermidis can present with exuberant fibrous tissue formation encasing the implanted device no systemic inflammatory response. Traditional cultures are often negative. The presence of these findings in patients who have an ICD or pacemaker indicates that an infectious process is ongoing and eventual removal of the entire implant will be necessary.
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References
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Almassi G.H., Olinger G.N., Troup P.J., Chapman P.D., Goodman L.R. Delayed infection of the automatic implantable cardioverter-defibrillator. J Thorac Cardiovasc Surg 1988;95:908-911.[Abstract]
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Troup P.J., Chapman P.D., Wetherbee J.N., Almassi G.H., Olinger G.N. Clinical features of AICD systemic infections. Circulation 1988;78(Suppl):II155.
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Vogt P.R., Sagdic K., Lachat M., Candinas R., von Segesser L.K., Turina M.I. Surgical management of infected permanent transvenous pacemaker systems: ten year experience. J Cardiac Surg 1996;11:180-186.[Medline]
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Tollefson D.F., Bandyk D.F., Kaebnick H.W., Seabrook G.B., Towne J.B. Surface biofilm disruption: enhanced recovery of microorganisms from vascular prostheses. Arch Surg 1987;122:28-43.
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Virden C.P., Dobke M.K., Stein P., et al. Subclinical infection of the silicone breast implant surface as a possible cause of capsular contracture. Aesthetic Plast Surg 1992;16:173-179.[Medline]
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Abstract
Introduction
