Unusual conservative treatment of a complicated pacemaker pocket infection: a case report

Abstract

Background: For patients with complicated generator pocket infection, expert consensuses universally advocate complete device and leads removal followed by delayed replacement on the contralateral side. We cured our patient by partial generator removal and reimplantation of sterilized pulse generator on the ipsilateral side. We also performed a literature review about incomplete removal therapy for the management of cardiac implantable electronic device infection.

Case presentation: An 86-year-old Chinese Han man was diagnosed as having third-degree atrioventricular block and received a permanent double-chamber pacemaker in his left prepectoral area 15 years ago. Nine years later, the entire system was removed because of confirmed infection, and a new device was reimplanted in the contralateral area. He developed skin necrosis around the pacemaker pocket after 1 year, and his generator was renewed without leads extraction at another medical center. He was subsequently admitted several times for surgical tissue debridement at another institution due to extended skin necrosis. At the time of the new admission, he had severe infection, heart failure, and hypoalbuminemia. He was diagnosed as having complicated pacemaker pocket infection. Our preferred treatment strategy was for complete removal of both the generator and transvenous pacing leads, and we intended to implant an epicardial pacemaker in our patient if necessary. However, he rejected the treatment strategy and firmly refused to replace his generator. We had to attempt a novel pacemaker-preserving strategy considering our patient's severe comorbidities. Finally, we cured him by partial generator removal and reimplantation of the sterilized pulse generator on the ipsilateral side. There was no sign of wound dehiscence or infection during a 6-month follow-up.

Conclusions: We would posit that partial removal of infected generators combined with conservative treatment may be a proper treatment of complicated generator pocket infection, especially for those who are susceptible to cardiac complications. Reimplantation of a sterilized pulse generator on the ipsilateral side may be an option if patients reject a new device and contralateral vascular condition is not really suitable. Opting for such treatment should be at the consideration of the primary care physician based on the condition of the patient.

Keywords: Antimicrobial therapy; Complicated pacemaker pocket infection; Conservative treatment; Microbes; Partial removal; Reimplantation; Temporary pacing.

Fig. 1

Appearance of the wound at the time of admission. Adherence of skin to the leads was eroded overtly and draining sinus can be observed on the right side of the upper chest

Fig. 2

a Appearance of the wound after irrigation (second week in the hospital). b Preoperative chest X-ray showed the generator was in the infraclavicular region

Fig. 3

a Appearance of the wound after reimplantation. b Postoperative chest X-ray showed the generator was reimplanted in different position on the same side

Fig. 4

Complete healing of the wound (sixth month after discharge)

Fig. 5

Clinical makers of infection were normal during a 6-month follow-up. CRP C-reactive protein, NEUT neutrophils, PCT procalcitonin, WBC white blood cells

Fig. 6

Timeline shows disease progression