This article describes an interesting case of automated implantable cardioverter defibrillator (AICD) extrusion fifteen months after implantation.  The case report is followed by a discussion of the causes and treatment of skin erosion following pacemaker/AICD insertion

Hanon, Sam

Schweitzer, Paul

Shapiro, Michael

English

PubMed

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A Rare, Late Complication after Automated Implantable Cardioverter-Defibrillator Placement

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Case Report
A Rare,  Late  Complication  after  Automated  Implantable
Cardioverter-Defibrillator Placement
Michael Shapiro, D.O., Sam Hanon, M.D., Paul Schweitzer, M.D.
Department of Cardiology, Beth Israel Medical Center, University Hospital and Manhattan
Campus for the Albert Einstein College of Medicine, New York, USA.
Address for correspondence: Michael Shapiro, D.O., Beth Israel Medical Center, Department of
Cardiology, First Avenue at 16th Street, Dazian Building, 11th Floor, New York, NY, 10003.
Email: shapiromi@rcn.com
Abstract
                This  article  describes  an  interesting  case  of  automated  implantable  cardioverter
defibrillator (AICD) extrusion fifteen months after implantation.  The case report is followed by
a discussion of the causes and treatment of skin erosion following pacemaker/AICD insertion.
Key words: pacemaker complication, skin erosion, extrusion
Case report
            The  patient  is  a  65  year  old  man  with  a  history  of  chronic  renal  insufficiency,
dyslipidemia, hypertension, peripheral arterial disease, and coronary artery disease status post
myocardial  infarction  in  1994.  He was  revascularized  with  3-vessel  coronary artery bypass
grafting  on  3/12/02  after  he  developed  unstable  angina.  His  post-operative  course  was
complicated by a deep venous thrombosis. Treatment was initiated with warfarin and the patient
was subsequently discharged from the hospital.  He was readmitted three weeks later with mild
shortness  of  breath.  A  ventilation/perfusion  scan  was  negative  for  pulmonary  embolism. 
However,  while  on  telemetry,  the  patient  had  an  episode  of  non-sustained  ventricular
tachycardia.  He underwent diagnostic electrophysiologic testing at which time he was inducible
for ventricular tachycardia.  On 4/2/02, an AICD was implanted.  He was discharged without
incident and did well for over a year without any arrhythmic event requiring ICD shock. One
week prior to the current admission the patient noted a skin tear over the AICD with protrusion
of the device to the anterior chest wall.  He visited his cardiologist to evaluate the extrusion of
the device at which time he was immediately referred for hospital admission.  
            The patient  admitted to minimal  skin tenderness over the site but denied bloody or
purulent drainage, fevers, chills, or malaise.  His medications included  metoprolol XL 50 mg
daily,  aspirin  81  mg  daily,  clopidogrel  75  mg  daily,  atorvastatin  10  mg  daily,  isosorbide
mononitrate  20 mg daily, and gabapentin  300 mg daily.  Social  history, family history,  and
review of systems were non-contributory.  
            On physical examination, the patient had a temperature of 97.8° F, blood pressure 122/78
mm Hg, pulse 86 beats per minute and regular, and respiratory rate of 20 breaths per minute.  He
was a well developed, well nourished male sitting comfortably in no distress.  Examination of
his neck revealed no JVD at 30°, normal carotid upstrokes without bruits, and no thyromegaly. 
His chest was clear and heart examination revealed a non-displaced point of maximal impulse
Indian Pacing and Electrophysiology Journal (ISSN 0972-6292), 4(4): 213-216 (2004)
Michael Shapiro, Sam Hanon, Paul Schweitzer,                                                      214
“A  Rare,  Late  Complication  after  Automated  Implantable  Cardioverter-Defibrillator
Placement ” 
with a normal apical impulse, normal S1 and S2 without an S3 or S4.  His pulse was regular with
an apical 2/6 holosystolic murmur with radiation to the axilla.  His anterior chest wall revealed a
well healed sternotomy scar with erythema in the left supraclavicular area at the point where his
AICD was extruding from his skin without drainage (see Fig. 1 and Fig. 2).  His abdomen was
obese  but  soft  without  hepatomegaly.  Neurologically,  he  was  grossly  intact.  His  lower
extremities revealed no edema and distal pulses were intact.  His initial laboratory results were
normal  including metabolic  profile,  complete  blood count  with  differential,  and coagulation
profile.  His  chest  radiograph revealed  clear  lungs,  normal  heart  size,  and  a  dual  chamber
pacemaker/defibrillator with leads in proper position.  His electrocardiogram (ECG) revealed a
normal sinus rhythm with right bundle branch block, left posterior fascicular block, and an old
inferior infarct.  This ECG was unchanged from prior tracings.  The patient was admitted to the
hospital  and  three  sets  of  blood  cultures  were  obtained.  He  was  subsequently  started  on
vancomycin 1 g intravenously q 12h. The following day his device was explanted and the pocket
debrided.  Blood  cultures  as  well  as  cultures  from  the  device  and  surrounding  skin  and
subcutaneous tissue revealed no growth.  He was continued on antibiotics and discharged from
the hospital without complications.  The discharge plan was to replace the AICD at a future date,
upon healing of the operative site.
  
Figure 1.  Photo of the patient depicting the erosion of the AICD through the skin.
Indian Pacing and Electrophysiology Journal (ISSN 0972-6292), 4(4): 213-216 (2004)
Michael Shapiro, Sam Hanon, Paul Schweitzer,                                                      215
“A  Rare,  Late  Complication  after  Automated  Implantable  Cardioverter-Defibrillator
Placement ” 
  
Figure 2.  Close up examination of AICD of same patient eroding through
the  skin.  Note  upper  right  corner  of  subcutaneous  pocket  shows severe
erythema with signs of pre-erosion.
Discussion
            This case illustrates an unusually severe form of pacemaker/AICD skin erosion.  This
rare complication has been previously described in the literature.  However, prior to the study
performed by Kiviniemi et al,1 most  of the existing data was based on information from the
1970s.2 This more recent investigation retrospectively analyzed four hundred forty-six patients
who received permanent pacemakers and reported the complications noted during implantation
or follow-up.  Pacemaker erosion was detected in 0.9% of the patients.  
            Two main culprits have been implicated in the pathogenesis of pacemaker extrusion.
First, infection of the site can lead to skin erosion.3 Obviously, prevention of and monitoring for
infection is paramount to averting this  process.  DaCosta  et  al.  performed a meta-analysis of
antibiotic  prophylaxis  for  pacemaker  implantation.4  They  concluded  that  antibiotics
administered during the peri-implant  period reduced the incidence of infective complications
following  pacemaker  implantation,  including  short-term  pocket  infection,  skin  erosion,  or
septicemia.
            The other cause of skin erosion is pressure necrosis of the overlying tissue and skin.3 
Gross pacemaker extrusion is usually signaled by a preceding period of “pre-erosion,” during
which there is discomfort and discoloration of thinning tissue tensely stretched over a protrusion
Indian Pacing and Electrophysiology Journal (ISSN 0972-6292), 4(4): 213-216 (2004)
Michael Shapiro, Sam Hanon, Paul Schweitzer,                                                      216
“A  Rare,  Late  Complication  after  Automated  Implantable  Cardioverter-Defibrillator
Placement ” 
of the pacing apparatus (Fig. 2).  Griffith et al. concluded that if pacemaker erosion is not caused
by  infection  it  can  be  successfully  managed  by  ipsilateral  re-implantation,  a  financially
advantageous solution.5 Identification of pre-erosion allows salvage of the pacing system, as the
hardware can be repositioned under the pectoralis muscle or in an abdominal location.
            Risk factors for skin erosion include factors related to the device itself as well as to the
implantation site. The mass and configuration of the pacemaker as well as the need for extra
hardware (e.g.,  lead adaptor)  in  the pocket  may lead to local  tension and pressure necrosis.
Additionally,  precise  surgical  construction  of  the  pacemaker  pocket  is  vital.  A  pocket  of
inadequate size or a paucity of subcutaneous tissue may contribute to local complications. The
pocket  plane  should  be  created  on  the  surface  of  the  muscle  since  superficial  pockets  lend
themselves to erosion.6     
            If true erosion occurs, the system is considered contaminated and current opinion favors
removal  of  the  generator  and  leads.  Extensive  debridement  of  the  pocket  and  prolonged
irrigation and antibiotic therapy may provide an alternate option to removal in cases of both
erosion and frank infection,7 but this approach is not generally preferred.  Attempts have been
made to preserve the implanted leads by debriding locally and severing the pacemaker leads
while leaving them in situ. However, given the relative safety and efficacy of percutaneous lead
removal, complete removal of the leads is the ideal approach if sterility is questioned.
References
1. Kiviniemi MS, Pirnes MA, Eranen HJ, Kettunen RV, Hartikainen JE.  Complications related
to permanent pacemaker therapy.  Pacing & Clinical Electrophysiology.  1999;22(5):711-20.
2.  Cohn JD, Santhanam R, Rosenbloom MA, Thorson RF.  Delayed pacemaker erosion due to
electrode seal defects.  Annals of Thoracic Surgery.  1979;28:445-450.
3.  Smyth  NPD,  Millette  ML.  Complications  of  pacemaker  implantation.  In:  Barold  SS,  ed.
Modern Cardiac Pacing. Mount Kisco, NY: Futura Publishing Co; 1985:257–304.   
4.  Da Costa A, Kirkorian G, Cucherat M, Delahaye F, Chevalier P, Cerisier A, Isaaz K, Touboul
P.  Antibiotic prophylaxis for permanent pacemaker implantation: a meta-analysis.  Circulation.
1998 May 12;97(18):1796-801.
5. Griffith MJ, Mounsey JP, Bexton RS, Holden MP. Mechanical, but not infective, pacemaker
erosion  may  be  successfully  managed  by  re-implantation  of  pacemakers.  Br  Heart  J.
1994;71:202–205. 
6.  Pavia  S,  Wilkoff  B.  The  management  of  surgical  complications  of  pacemaker  and
implantable cardioverter-defibrillators.  Curr Opin Cardiol.  2000;16:66-71.
7.  Hurst  LM, Evans  HB,  Winale  B,  Klein  GJ.  The  salvage  of  infected  cardiac  pacemaker
pockets using a closed irrigation system.  Pacing & Clinical Electrophysiology.  1986;9:785-792.
Indian Pacing and Electrophysiology Journal (ISSN 0972-6292), 4(4): 213-216 (2004)


Antibiotic prophylaxis for permanent pacemaker implantation: a meta-analysis. Circulation.

but not infective, pacemaker erosion may be successfully managed by re-implantation of pacemakers.

Complications of pacemaker implantation.

Complications related to permanent pacemaker therapy. Pacing & Clinical Electrophysiology.

Delayed pacemaker erosion due to electrode seal defects. Annals of Thoracic Surgery.

The management of surgical complications of pacemaker and implantable cardioverter-defibrillators.

The salvage of infected cardiac pacemaker pockets using a closed irrigation system.

A Rare, Late Complication after Automated Implantable Cardioverter-Defibrillator Placement

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