Ann Thorac Surg 2001;71:2038-2039
© 2001 The Society of Thoracic Surgeons
Case report
Infection of a retained permanent epicardial pacemaker lead
Yoshikazu Hachiro, MDa,
Seiya Kikuchi, MDa,
Masayoshi Ito, MDa,
Kazuhiro Takahashi, MDa,
Tomio Abe, MD, PhDa
a Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
Accepted for publication April 5, 2000.
Address reprint requests to Dr Hachiro, Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo 060-8543, Japan
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Abstract
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Infection of a retained permanent epicardial pacemaker lead rarely causes mediastinal infection. A 21-month-old boy who had undergone an arterial switch operation at day 6 of life presented with mediastinal infection 3 months after removal of the generator. Removal of the infected pacemaker leads with the inflammatory granuloma was performed under extracorporeal circulation. The mediastinal infection developed from the retained epicardial pacemaker lead infection.
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Introduction
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Infections related to permanent pacemakers and retained pacemaker leads, although uncommon, remain a difficult diagnostic and management problem [1–3]. Infection of a retained permanent epicardial pacemaker lead after removal of the generator is rare.
A 21-month-old boy who had undergone an arterial switch operation for transposition of the great arteries on day 6 of life presented with mediastinal infection due to infection of a retained permanent epicardial pacemaker lead. A permanent pacemaker was placed for complete atrioventricular block on day 20 of life. The generator, which had been placed on the abdominal wall, was removed at 17 months of age due to the recovery of normal sinus rhythm. Severe fever and abdominal pain occurred 3 months later. Computed tomography (CT) showed a mass around the pacemaker leads on the anterior wall of the right ventricle (Fig 1A). Gallium scintigraphy demonstrated inflammation at this location (Fig 1B). Echocardiography and angiography revealed blood flow from the right ventricle to the mass slightly. The white blood cell count and C-reactive protein concentration were 8800/dl and 7.31 mg/dl, respectively. Mediastinal infection and a right ventricular pseudoaneurysm were suspected. He was stabilized with intravenous antibiotics.
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Fig 1. (A) Computed tomographic scan of the thorax showing a mass lesion (white arrow) located in the retrosternal portion. The pacemaker leads (black arrow) are detected into the mass. (B) Corresponding Gallium scintigraphy (front view). An enhancement is noted on the anterior wall of the right ventricle and on the site of pacemaker leads (arrow).
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The patient was taken to the operating room and a median sternotomy and abdominal incision at the implant site were made. Extracorporeal circulation was established. A giant inflammatory granuloma around the pacemaker lead was found under the sternum, firmly adherent to the surrounding structures. The infection appeared to have originated in the generator pocket. The infected pacemaker lead, which was adherent to the anterior free wall of the right ventricle, was removed. The generator pocket was debrided. The infection was localized to the granuloma. A deep sternal wound infection was not identified. The sternotomy was closed primarily after two drains were placed. The cultures grew methicillin-resistant Staphylococcus aureus. Vancomycin was continued postoperatively. The patient’s recovery was uneventful. At the 13-month follow-up, there were no signs of infection.
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Comment
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The incidence of complications associated with retained, nonfunctional, epicardial pacemaker leads has not been reported. Usually, noninfected leads do not pose a significant problem. In this case, infection of the retained leads, which probably occurred at the time of generator removal, caused the mediastinal infection. The inflammatory granuloma developed over a period of 3 months.
When a pacemaker lead infection occurs, removal of the entire pacing system is necessary. However, removal of the pacing leads is often technically difficult. Cardiopulmonary bypass was used in this operation because mediastinal infection and a right ventricular psudoaneurysm were suspected. Consequently, great care was taken during the sternotomy. Extracorporeal circulation allowed for the safe extraction of the giant granuloma, particularly since the mass appeared to derive its blood supply directly from the right ventricle.
Epicardial pacing is used in the great majority of pacemaker implantation in infants and children. Removal of the entire pacemaker system requires general anesthesia and a thoracotomy. The perioperative morbidity in these cases is relatively high. Only the generator was removed in our patient because of concern that the arrhythmias might recur, and because a thoracotomy would be required for lead removal. Parry and associates [3] have recommended that pacing leads, which could become infected, should be removed. When the pacemaker system is no longer needed, we believe the entire pacemaker system should be removed, even if cardiopulmonary bypass is required.
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References
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Lewis A.B., Hayes D.L., Holmes D.R., Jr, Vlietstra R.E., et al. Update on infections involving permanent pacemakers. Characterization and management. J Thorac Cardiovasc Surg 1985;89:758-763.[Abstract]
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Choo M.H., Holmes D.R., Jr, Gersh B.J., et al. Infected epicardial pacemaker systems. Partial versus total removal. J Thorac Cardiovasc Surg 1981;82:794-796.[Abstract]
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Parry G., Goudevenos J., Jameson S., Adams P.C., et al. Complications associated with retained pacemaker leads. PACE 1991;14:1251-1257.
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Abstract
Introduction
