Ann Thorac Surg 2007;83:2230-2232
© 2007 The Society of Thoracic Surgeons
Case Reports
Migration and Colon Perforation of Intraperitoneal Cardiac Pacemaker Systems
Ali Dodge-Khatami, MD, PhDa,*,
Carl L. Backer, MDb,
Martin Meuli, MDc,
René Prêtre, MDa,
Maren Tomaske, MDd,
Constantine Mavroudis, MDb
a Division of Congenital Cardiovascular Surgery, University Children’s Hospital, Zürich, Switzerland
c Department of Surgery, University Children’s Hospital, Zürich, Switzerland
d Division of Pediatric Cardiology, University Children’s Hospital, Zürich, Switzerland
b Division of Pediatric Cardiothoracic Surgery, Children’s Memorial Hospital, Chicago, Illinois
Accepted for publication December 21, 2006.
* Address correspondence to Dr Dodge-Khatami, Division of Congenital Cardiovascular Surgery, University Children’s Hospital Zürich, Steinwiesstrasse 75, Zürich, CH-8032, Switzerland (Email: ali.dodge-khatami{at}kispi.unizh.ch).
 |
Abstract
|
|---|
Epicardial pacemaker systems include pacing leads and a generator, which exceptionally may have to be implanted in the abdomen. We report three such pediatric cases where severe intraabdominal complications occurred owing to migration and erosion of the generators into visceral organs and urge extreme caution with this technique.
|
Introduction
|
|---|
Implantation of epicardial pacemaker generators after lead insertion through a sternotomy or thoracotomy is classically in the sheath of the abdominal rectus muscle. In very thin patients or in small babies, insufficient subcutaneous tissue and muscle cannot properly harbor even the smallest of generators, and an intraperitoneal position is used by default. We report 3 patients in two different institutions with the same surgical implant technique and intraabdominal complications, albeit with differing degrees of severity.
|
Case Reports
|
|---|
Patient 1
A 9-year-old girl with D-transposition of the great arteries and a ventricular septal defect had undergone an arterial switch operation as a neonate. This was complicated by postoperative complete heart block that required insertion of a DDD epicardial pacing system through a sternotomy. The generator was placed under the sheath of the left abdominal rectus muscle.
At the age of 8 years, pacemaker battery exhaustion and systemic ventricular dysfunction indicated a switch to a biventricular dual-chamber pacing mode. It was not possible to create a large enough pocket to accommodate the much thicker upgraded generator in this very thin patient, and intraperitoneal implantation was performed, with fixation to the internal abdominal wall with a single, nonabsorbable suture of polypropylene.
She presented 11 months afterwards with a 2-month history of vague abdominal pain and nausea that culminated in acute peritoneal signs the night of her admission to the hospital. An abdominal roentgenogram and computed tomography scan (Fig 1) demonstrated free intraabdominal air and the generator in the left lower quadrant.
View larger version (121K):
[in this window]
[in a new window]
|
Fig 1. A computed tomography scan shows the pacemaker generator through the wall of the sigmoid, with free intraabdominal air.
|
|
Emergency surgery was performed in this severely septic and pacemaker-dependent patient. A transvenous ventricular lead was first inserted and connected to a new generator as a backup before the intraabdominal part of the operation was undertaken. In the abdomen, there was free pus and a covered abscess. A point of entry was found in the descending colon. The generator had migrated to the sigmoid, where further travel was stopped by the leads, which were stretched to their full length. The generator was manipulated in a retrograde fashion to its point of entrance and removed from the colon (Fig 2). The generator still carried the intact knot of the tacking nonabsorbable suture that had torn off the abdominal wall, and was disconnected from the leads, which were temporarily capped and replaced in the old pocket. After thorough abdominal lavage, the colonic perforation was directly sutured, and the abdomen closed.
View larger version (140K):
[in this window]
[in a new window]
|
Fig 2. The generator was manipulated in a retrograde fashion to its point of entry in the descending colon and explanted.
|
|
After improvement of the patient’s general condition with intravenous antibiotics, the prior left lateral thoracotomy incision was reentered. The transvenous ventricular lead and the old infected epicardial leads were explanted, and new epicardial leads were implanted and connected to a biventricular dual-chamber generator, which was placed between the scapular muscles and the external rib cage, as already described in detail elsewhere [1]. She made an uneventful recovery after prolonged intravenous antibiotic treatment.
Patient 2
A radiograph (Fig 3) was obtained to locate the generator in a patient who, as a baby, had undergone placement of an epicardial single-chamber ventricular pacing system for complete congenital heart block in the late 1980s. The pacemaker generator was placed in a pocket fashioned from Gore-Tex (WL Gore & Associates, Flagstaff, AZ) in the preperitoneal space. The pacemaker had migrated and was in a position immediately superior to the bladder. The generator was removed through a suprapubic incision, and a new transvenous system was placed.
Patient 3
A patient with a functional single ventricle underwent two initial palliative operations before undergoing an atriopulmonary Fontan procedure at 5 years of age. He required implantation of an epicardial pacemaker at the age of 11, which was inserted through a left thoracotomy, with the pacemaker generator placed in a pocket in the left lumbar retroperitoneal space. The generator was changed at 18 years of age.
At age 21, the patient complained of left flank pain, developed a fever, and had positive results on blood cultures. On roentgenogram, the generator appeared to have migrated into the suprapubic area. A suprapubic laparotomy was performed, and the generator was discovered to have eroded into the colon. The pacer pocket was explored, and an abscess was found to have ruptured into the colon. After generator extraction from the colon via the rectum, partial resection of the colon and a colostomy were performed. He underwent a thoracotomy and the pacemaker electrodes were removed from the epicardial surface of the heart. He was treated with a temporary transvenous system, followed by a permanent transvenous, atrial pacemaker system. The infection was treated with antibiotics for 6 weeks and did not recur. The colostomy was later taken down. The patient underwent a successful Fontan conversion procedure at the age of 31.
|
Comment
|
|---|
Epicardial pacemaker leads are increasingly implanted in patients with congenital heart disease, and evidence of similar or superior long-term results compared with transvenous leads is accumulating [1, 2]. Although it is almost always possible in larger patients to create a subcutaneous/inframuscular pocket for generator placement, this is very difficult in newborns and infants, and therefore, placing the generator intraabdominally is relatively common practice in these low-weight patients. Perforation of a generator into the colon has been described in adult patients [3, 4], and in this report we present generator perforation in children.
The three cases reported here illustrate the dangers of this approach in older children and adolescents, in whom an intraperitoneal generator placement should be avoided. In the abdomen, the pacing generator and leads can potentially create adhesions, leading to ileus, volvulus, and eventually bowl necrosis, or perforate into organs such as the bowel and cause peritonitis. These potentially severe complications should make the intraperitoneal location a last-resort solution for pacemaker implantation.
On the dislodged battery in Patient 1, we found an intact knot of polypropylene suture, whose cut tips can be sharp and erode into a hollow organ. When an intraperitoneal approach is unavoidable, a soft, nonabsorbable suture such as silk is strongly advised.
Finally, patients, parents, and physicians alike should have a high index of suspicion when peritoneal symptoms are present, leading to a simple work up with an abdominal roentgenogram to reveal a migrating pacemaker in the abdomen.
|
References
|
|---|
- Dodge-Khatami A, Kadner A, Dave H, Rahn M, Prêtre R, Bauersfeld U. Left heart atrial and ventricular epicardial pacing through a left lateral thoracotomy in children: a safe approach with excellent functional and cosmetic results Eur J Cardiothorac Surg 2005;28:541-545.[Abstract/Free Full Text]
- Dodge-Khatami A, Johnsrude C, Backer CL, Deal BJ, Strasberger J, Mavroudis C. A comparison of steroid-eluting epicardial versus transvenous pacing leads in children J Cardiac Surg 2000;15:323-329.[Medline]
- Metzger B, Lachmann W. Cardiac pacemaker perforation of the transverse colon in the infected pacemaker system Z Gesamte Inn Med 1980;35:345-347.[Medline]
- Siclari F, Uhlschmid G, Zwicky P, Turina M. Intracolonic migration of a pacemaker generator Thorac Cardiovasc Surg 1986;34:338-339.[Medline]
Top
Abstract
Introduction
