The number of patients requiring a cardiac implantable electronic device (CIED) has increased due to expanding indications and improved procedural risks.1 Unfortunately, this has also resulted in a concomitant increase in the number of CIED infections often requiring complete system extraction.2 In these cases, reimplantation on the contralateral side is preferred to reduce the chance of recurrent infection. However, vascular access may be limited due to catheters for therapeutic agents, arteriovenous fistula, history of radiation treatments, or prior surgery. Rarely, other patient anatomical variants may preclude the standard approach. The leadless pacemaker is an excellent option, but is not appropriate in patients requiring the need for atrioventricular synchrony. Therefore, alternate sites for implantation may need to be considered. A knowledge of all options is vitally important for the implanter to ensure an optimal outcome.
We report a case of a patient who underwent device system extraction due to infection and required reimplantation in an alternative site due to congenital absence of his pectoralis muscle.
A 54-year-old male with sick sinus syndrome, hypothyroidism, hypertension, and paroxysmal atrial fibrillation presented from an outside hospital with an eroded pacemaker generator placed 5 years previously in the right pectoral region (Figure 1). He was afebrile, his white blood cell count was normal, and his blood cultures were negative. Per our standard protocol, with cardiothoracic surgery backup, the patient underwent successful laser lead extraction under general anesthesia of both atrial and ventricular leads without complication.
At the time of the lead extraction, the patient had underlying sinus bradycardia with heart rates of 40-50 bpm. The reimplantation plan was discussed at length, initially focusing on the contralateral option. However, the patient was opposed to this option due to the congenital absence of his left-sided pectoralis muscle, a finding evident on physical exam and confirmed by CT scan (Figure 2). At the time, the decision was to forego reimplantation unless symptoms dictated.
However, two weeks later, the patient had ongoing symptoms of marked fatigue and presyncope correlating to sinus bradycardia less than 50 bpm along with evidence of chronotropic incompetence. The patient strongly wished to have reimplantation of a pacemaker, but again was concerned about the location of the device.
Description of the absence of the pectoralis muscle has been attributed most notably to Dr. Alfred Poland while he was a medical student at Guy’s Hospital in 1841. During a dissection on a cadaver of a convict, he noted the absence of a pectoralis muscle along with brachysyndactyly (congenital anomaly of the hand with shortness of fingers, often including webs between digits).3 Although he wrote only of the muscle findings, he had the subject’s hand removed and preserved for posterity, where it remains today in the Gordon Museum of Pathology in London (Figure 3). Over 100 years later, the eponym was declared, and Poland syndrome typically refers to the absence of the pectoralis major and/or minor muscles, with variable other anomalies such as other chest wall, upper extremity, and various hand anomalies.4 In our case, this patient had only absence of pectoralis major and minor, but no other associated anomalies.
In general, options for device and lead placement in the setting of CIED infection requiring reimplantation included:
1. Contralateral pectoral implantation;
2. Delayed ipsilateral implantation, located more medial or lateral;
3. Early ipsilateral implantation, either via submuscular implantation or a low lateral thoracic site and lateral subcutaneous site (often described same day or up to 10 days post explant);
4. Transfemoral approach utilizing the femoral vein and tunneled to the abdominal cavity;
5. Leadless pacemaker implant;
6. Epicardial approach;
7. Contralateral placement of leads in the subclavian vein and tunneled to the abdomen.
Contralateral pectoral implantation is the standard route and has been performed as early as the same day after low-grade local infection.5 The patient chose against this option given the complete lack of muscle and minimal subcutaneous tissue, which could have led to increased discomfort on the rib cage, device migration, and increased chance of infection. Early reimplantation using an ipsilateral option was also discussed with the patient given his insistence to avoid the left pectoral region. Ipsilateral implantation with submuscular placement has the theoretical advantage of a tissue plane to help prevent the spread of infection.6 Another ipsilateral approach involves using a low lateral thoracic incision and axillary venipuncture in the hope of creating greater physical separation to the infected tissue and reducing muscular bleeding.7 These approaches have primarily been described when patients require early reimplantation due to pacemaker dependency, and little options exist other than prolonged semi-permanent device placement. In our case, the Infectious Disease service and patient were too concerned about the risk of infection and wanted other options.
Transfemoral approaches utilizing longer 85 cm leads with the generator in the abdominal fascial plane have been described, but may have higher dislodgment and infection rates.8-10 Leadless pacemaker implantation has numerous advantages but would not be appropriate in this patient, who needed atrioventricular synchrony. While epicardial leads may be helpful in cases of infection, they would have had the same dilemma regarding the optimal generator site. Therefore, none of these seemed to offer a suitable solution.
For that reason, after extended discussion, the decision was made to implant the leads via the left subclavian vein and tunnel them to a pacemaker generator in the pre-fascial plane of the abdominal cavity.
The patient was prepped and draped to allow access to the pectoral and abdominal regions. A 4 cm incision was created in the left infraclavicular region and venipuncture was performed with standard sheaths placed. Long (85 cm) atrial and ventricular leads were advanced to the right atrial appendage and right ventricular apex with satisfactory thresholds, sensing, and impedances. With surgical assistance, a 4 cm incision was made in the abdominal region and carried down to the external oblique fascia. A pocket was then created inferiorly. A vascular tunneling device was advanced from this pocket to the infraclavicular incision, and the pacemaker and leads were placed in the device pocket, where standard closure methods were then utilized (Figure 4). The patient tolerated the procedure well without complication, and subsequently reported complete resolution of his symptoms.
Alternative sites for implantation must occasionally be considered due to venous occlusion, infection, and patient preference. Our patient with symptomatic bradycardia and Poland syndrome underwent transvenous extraction of his infected device and had successful reimplantation on the contralateral side with leads tunneled to his abdominal fascial plane.
Disclosures: The authors have no conflicts of interest to report regarding the content herein.
- Greenspon AJ, Patel JD, Lau E, et al. Trends in permanent pacemaker implantation in the United States from 1993 to 2009; increasing complexity of patients and procedures. J Am Coll Cardiol. 2012;60:1540-1545.
- Voigt A, Shalaby A, Saba S. Rising rates of cardiac rhythm management device infections in the United States: 1996 through 2003. J Am Coll Cardiol. 2006;48:590-591.
- Poland A. Deficiency of the pectoral muscles. Guys Hosp Rep. 1841;6:191-193.
- Urschel HC. Poland’s Syndrome. Chest Surg Clin N Am. 2000;10:393-403.
- Mountantonakis SE, Tschabrunn CM, Deyell MW, Cooper JM. Same-day contralateral implantation of a permanent device after lead extraction for isolated pocket infection. Europace. 2014;15:252-257.
- Al-Batteineh M, Sajadi S, Fontaine JM, Kutalek S. Axillary subpectoral approach for pacemaker or defibrillator implantation in patients with ipsilateral prepectoral infection and limited venous access. J Interv Card Electrophysiol. 2010;27:137-142.
- Liang JJ, Schaller RD, Modi DS, et al. Low lateral thoracic site for cardiac implantable electronic device implantation: a viable alternative in patients with limited access options after infected device extraction. Heart Rhythm. 2017;14(10):1506-1514.
- Mela T, McGovern BA, Gatan H, et al. Long-term infection rates associated with the pectoral versus abdominal approach to cardioverter-defibrillator implants. Am J Cardiol. 2001;88:750-753.
- Mathur G, Stables RH, Heaven, D, Ingra A, Sutton R. Permanent pacemaker implantation via the femoral vein: an alternative in cases with contraindications to the pectoral approach. Europace. 2001;3(1):56-59.
- García Guerrero JJ, De La Concha Castañeda JF, Fernández Mora G, et al. Permanent transfemoral pacemaker: a single-center series performed with an easier and safer surgical technique. Pacing Clin Electrophysiol. 2005;28:675-679.