Salvage of pacemakers and automatic implantable cardioverter-defibrillators using dermis grafts.
BACKGROUND
Thin patients with thoracic pacemakers and automatic implantable cardioverter-defibrillators often have minimal tissue over the devices, with erosion through the surface a major concern. This erosion can lead to device infection and need for removal, or primary device infection can, in turn, lead to erosion. Even worse is exposure and infection of the leads to the heart, with fatalities having occurred. Pressure symptoms, as with shoulder seatbelt straps, can occur, and the visible deformity may be objectionable.


METHODS
To correct these problems without device removal, we used a novel surgical approach. Thirteen patients had 15 grafts, of either the acellular dermal graft AlloDerm (LifeCell Corp, Branchburg, NJ [n = 13 for threatened exposure or pressure symptoms, including two repeats]) or autogenous dermis (n = 2 for existing open wounds with chronic drainage) placed over the devices.


RESULTS
After all graft procedures, there was no skin breakdown; exposure and extrusion were completely prevented. Follow-up was 3 to 68 months (mean 36.8). The 2 open wound patients treated with dermis autografts had no recurrence of wound breakdown. Most patients with pressure symptoms had reduction in tenderness and pain. Patients liked the visible softening of the device contour, but not the subtly increased forward projection. The only immediate complication was one rapidly expanding hematoma leading to graft removal. One late complication was a mild infection, treated successfully.


CONCLUSIONS
Acellular human dermal allografts, or live dermis autografts, provided significant protection over cardiac pacing devices in 13 patients with 15 grafts, with no subsequent surface exposures or extrusions.
Division of Plastic and Reconstructive Surgery, Scripps Clinic and University of California San Diego, La Jolla, California 92037, USA. rudolph.ross@scrippshealth.org
Ross
R
Rudolph
Michael R
MR
Smith
Guy P
GP
Curtis
D000368:Aged; D000369:Aged, 80 and over; D002474:Cell-Free System; D017147:Defibrillators, Implantable / Q000009:adverse effects*; D020405:Dermis / Q000637:transplantation*; D004567:Electrodes, Implanted / Q000009:adverse effects; D005260:Female; D005500:Follow-Up Studies; D006406:Hematoma / Q000209:etiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D010138:Pacemaker, Artificial / Q000009:adverse effects*; D010146:Pain / Q000209:etiology / Q000517:prevention & control*; D016459:Prosthesis-Related Infections / Q000209:etiology / Q000517:prevention & control*; D012086:Reoperation; D016879:Salvage Therapy / Q000379:methods*; D012867:Skin / Q000473:pathology; D016038:Skin Transplantation / Q000009:adverse effects / Q000379:methods*; D014184:Transplantation, Homologous / Q000379:methods