title: Salvage of exposed implantable cardiac electrical devices and lead systems with pocket change and local flap coverage.
abstract: Erosion and exposure of pacemaker (PPM) and implantable cardiac defibrillator (ICD) devices are potentially dire complications, which have classically required the removal of the entire generator and lead systems. This study evaluates a series of cases wherein debridement, irrigation, pocket change, and local flap coverage were used for the successful salvage of indwelling leads after exposure and infection of implantable cardiac defibrillator devices. Patients with skin erosion, infection, and/or exposure of prepectoral infraclavicular cardiac defibrillator devices were treated over a 23-month period between June 2004 and April 2006. The surgical technique involved wide excision of the exposure site with a rhombic incision pattern, followed by removal of the generator unit and complete debridement of the peridevice capsule. Subclavian atrioventricular (AV) leads were preserved. The pocket was irrigated with antibiotic solution. A new pocket plane was selected and developed, and a new generator unit was implanted. A rhombic flap was developed and transposed to achieve tension-free closure over closed suction drains. Data were reviewed retrospectively. Six patients were treated, all male, mean age 66 years (range, 50 to 83 years). All patients presented with "new" exposure of the implantable generator within 48 hours. None demonstrated gross purulence, sepsis, or endocarditis. Initial gram stain was negative for bacteria in all cases, 1 (17%) grew sensitive Staphylococcus epidermidis species. Mean follow-up is 22 months (range, 8 to 31 months). One patient (17%) developed a hematoma, successfully treated by aspiration. Five patients (83%) were treated successfully, with no wound dehiscence, generator or lead exposure, or recurrence of infection. One patient (17%) developed drainage and exposure at a separate site (AV lead) at 10 months postoperative and required generator and lead explantation and site change to the contralateral anterior chest wall. In conclusion, in the absence of sepsis or gross infection, skin excision, pocket change, generator change with lead preservation, closed-suction drainage, and flap coverage for tension-free closure should be considered in the treatment of early ICD and PPM exposure.
authors.affiliation: Departments of Surgery, Divisions of Plastic Surgery, Mount Sinai School of Medicine, New York, NY, USA. adam@kolkermd.com
authors.forename: Adam R
authors.initials: AR
authors.lastname: Kolker
authors.forename: Jeremiah S
authors.initials: JS
authors.lastname: Redstone
authors.forename: John P
authors.initials: JP
authors.lastname: Tutela
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017147:Defibrillators, Implantable; D004322:Drainage; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010138:Pacemaker, Artificial; D011183:Postoperative Complications / Q000601:surgery*; D012086:Reoperation; D012189:Retrospective Studies; D013524:Surgical Flaps; D013514:Surgical Procedures, Operative / Q000379:methods*