With ever-increasing obesity problems plaguing Americans, it is imperative that medical professionals recognize and understand the new complications that accompany it and take them into account during procedures. It is projected that by 2030, all 50 states will have obesity rates above 44%, while 39 of these states will have rates above 50%. Even further, 13 states are projected to have obesity rates exceeding 60%.1 A common complication seen when implanting cardiac devices such as pacemakers or defibrillators is tissue displacement occurring when the patient is supine versus standing upright. Patients with large amounts of chest and/or abdominal adipose tissue often shift this added weight near their shoulders while supine, causing anatomical landmarks to be misplaced. When this occurs, cardiac incisions for devices can often be placed in more inferior locations. This gives way to complications when the patient sits upright because there will be an inferior shift in adipose tissue, which can cause the implanted device or leads to become dislodged.
To compensate for a shift in adipose tissue when supine, displacement or retraction must occur in order to replicate an upright position and allow for normal landmark findings. This will prevent the device from being improperly placed and causing a large shift when the patient changes from being in the supine to upright position.
We have seen an increase in instances of lead dislodgement in obese patients due to adipose shifting. In our lab, we compensate for displacement with the use of silk tape. We place a band of tape inferior from the surgical prep site transversely to allow for even retraction of the tissue and replicate an upright position.
The following two case examples discuss the incision site with the initial device implantation and the follow-up repositioning after having the adipose properly draped downward.
It is important to note that both patients discussed here had increased amounts of chest adipose. Patient #1 had a BMI greater than 30, while patient #2, even with a BMI around 25, had a large proportion of chest adiposity. Both patients had indications for pacemakers and had successful implantations by physicians outside of our institution. Three months after the initial pacemaker implantation, patient #1 was found to have a right atrial lead dislodgement. Lead revision was performed by a second physician outside of our institution. Approximately six months later, she was evaluated at our institution and found to have right ventricular lead dislodgement. Fluoroscopic evaluation revealed that patient #1 had significant inferior displacement of her pacemaker (Figure 1). Due to the severity of the displacement, we ex0planted the device and leads, and reimplanted a new device with new leads in a more superior position on the patient’s chest.
Patient #2 did not experience lead dislodgement, but upon evaluation at our institution, was found to have indications for a pacemaker upgrade to a biventricular pacemaker secondary to decreased left ventricular ejection fraction. Upon preparation for her upgrade procedure, it was found that her device had shifted in an inferior direction, essentially making the original implant site not usable for this second procedure. Therefore, the original device was explanted and a new device was implanted in a superior incision site. The original lead was pulled up to the new device without having to be explanted and replaced.
The revision procedures for both patients were performed with draping and preparation to compensate for the adipose displacement that was not previously accounted for in the original pacemaker procedures. Silk tape was used to retract chest adipose tissue in an inferior direction, and this resulted in a significant change in location of incision landmarks (Figures 1-7). To accomplish this, the tape was generally applied below the areola and traction was applied. In the case the tape must be applied above the areola, the areola is protected by a circular Telfa. The tape was fixed to the soft knee restraint we use in all of our implant cases. Positioning of the adipose tissue during traction was done in a way to simulate the patient in an upright position. It generally takes three 2-inch strips of silk tape to adequately position the adipose tissue without applying over traction to one area of the tissue. The use of three strips additionally allows for left and right alignment of the adipose tissue. Post-repositioning chest x-rays in the upright position were similar to the supine position, thus showing the importance of proper adipose displacement draping.
- F as in Fat: How Obesity Threatens America’s Future 2012. Trust for America’s Health. September 2012. Available online at http://healthyamericans.org/report/100/. Accessed Aug 13, 2013.