Axillary subpectoral approach for pacemaker or defibrillator implantation in patients with ipsilateral prepectoral infection and limited venous access

Salvage of Infected Cardiac Implantable Electrical Devices with Subpectoral Plane Pocket Revision

Introduction Infection of cardiac implantable electrical devices (CIEDs) may lead to serious complications. Complete CIED explantation is expensive, requires expertise, not free from complications, and may not be an option in patients with device dependence.

Aim To highlight that carefully selected infected CIEDs can be salvaged by placing the device in a subpectoral pocket below the pectoralis major muscle. We conducted a retrospective descriptive observational study.

Material and Methods Twelve patients (10 male and two female) with erosion, exposure or infection of infraclavicular, subcutaneously placed CIED were treated over a 30-month period between July 2018 and December 2020. The technique involved debridement and excision of a peridevice capsule, creating a subpectoral pocket beneath the pectoralis major muscle, and placing the CIED in a new pocket with total muscle coverage and closure of skin without tension.

Results Twelve patients ( m = 10; f = 2) with a mean age of 65 years (range, 46–82 years) presented with infection of CIED within 9 months of implantation. None had sepsis or endocarditis. In nine patients, CIEDs were successfully salvaged with relocation to subpectoral pocket. Mean follow-up was 20 months (range, 8–30 months). Three out of 12 developed reinfection that ultimately required CIED explantation. There was no mortality.

Conclusion In the absence of sepsis or endocarditis, infected CIEDs may be attempted at salvage by subpectoral pocket placement. This obviates the need for potentially risky explantation or replacement of expensive CIEDs.

Safety and feasibility of implanting a transvenous implantable cardioverter defibrillator (TV-ICD) in the left axilla

BACKGROUND

Transvenous implantable cardioverter defibrillator (TV-ICD) systems are commonly implanted in the left anterior chest because of an easier implantation and better defibrillation threshold. This study aimed to evaluate the safety and feasibility of left axillary implantations of TV-ICD systems.

METHODS

We performed left axillary TV-ICD implantations and compared that to the major complication rate and operation time of the conventional TV-ICD implantation site (left anterior chest). The electrical parameter trends were also assessed in the left axilla group.

RESULTS

Seventy-six consecutive patients were evaluated for the analysis. Thirty-one patients had their system implanted in the left axilla and the reasons for the implantations included 29 patients for cosmetic reasons and two for post-infection conditions. The operation time and major complication rate were similar between the two groups (left anterior chest vs. left axilla: 134±62.4 min vs. 114±33.5 min, p = .11, 1/45 patient, 2.2% [pocket hematoma] vs. 1/31 patient, 3.2% [lead dislodgement], p = .77). During the follow up period (4.9±2.3years), no lead interruptions were observed in either group. The electrical lead parameters at the time of the implantation and follow up were similar in the study group (R wave sensing 20.8±33.4 vs. 11.2±7.42 mv, p = .34; lead impedance 464±64.7 vs. 418±135ohm, p = .22; pacing threshold [at 0.4 ms] 1.0±0.76 vs. 1.21±0.93V, p = .49).

CONCLUSION

TV-ICD implantations in the left axilla were performed safely without increasing the operation time as compared to the conventional ICD implantation site. ICD implantations in the left axilla are an alternative in those not suitable for implanting TV-ICDs in the conventional implantation site.

Salvage of Threatened Cardiovascular Implantable Electronic Devices: Case Series and Review of Literature

BACKGROUND

The treatment of infected or exposed cardiac pacing and defibrillator devices is controversial. The conservative and widely accepted management calls for removal of the device and leads with immediate or delayed replacement of new components in a new site. Lead extraction carries a 2% major complication risk. In this article, we describe our experience with device salvage techniques and review the current literature.

METHODS

This is a retrospective case series of consecutive patients with infected, exposed, or at-risk implanted cardiac devices that were treated with aggressive surgical debridement, local pocket irrigation, and revision. A comprehensive review of the literature regarding device infection management was performed.

RESULTS

Ten patients with threatened devices were identified. Surgical revision with the aim to salvage the device was successful in 8 (80%) of 10 cases. Seventeen retrospective publications were reviewed. All indicate success with attempted salvage surgery, but heterogeneity of data limits formal meta-analysis and prevents management recommendations.

CONCLUSIONS

Cardiac pacing and defibrillator devices with low-grade infection or threatened exposure may be salvaged without explantation. Despite the lack of clear management guidelines or data, plastic surgeons may be asked to assist in the management of threatened cardiac devices. Further prospective trials are required to evaluate the safety, efficacy, and cost-effectiveness of attempted implant salvage.

Low lateral thoracic site for cardiac implantable electronic device implantation: A viable alternative in patients with limited access options after infected device extraction

BACKGROUND

Device reimplantation after extraction because of cardiac implantable electronic device (CIED) infection in pacemaker-dependent patients can be challenging in individuals with limited access options.

OBJECTIVE

The purpose of this study was to describe a straightforward, low lateral thoracic implantation technique for patients with a patent axillary vein but unavailable bilateral pectoral sites.

METHODS

Nine pacemaker-dependent patients (mean age 70 ± 13 years, 7 male) who underwent CIED extraction and low lateral thoracic reimplantation in whom bilateral pectoral sites were unavailable were included in the study.

RESULTS

Extraction was performed a median of 10 (interquartile range [IQR] 8-13) days before CIED reimplantation (4 dual-chamber, 3 single-chamber, 2 cardiac resynchronization therapy). The new generator was implanted in the low lateral thoracic region ipsilateral to the extracted generator in 7 patients (78%) and contralateral in 2 patients (22%), via a subcutaneous pocket in 6 (67%) and submuscular pocket in 3 (33%). Median procedure duration was 85 (IQR 61-116) minutes, median fluoroscopy time was 7.2 (IQR 5.7-10.9), minutes and median fluoroscopy exposure was 26.0 (IQR 10.0-110.5) mGy. No acute complications occurred. Over median follow-up of 92 (IQR 31-131) days, 1 patient experienced right atrial lead dislodgment (122 days postimplantation) requiring lead revision. No patients experienced recurrent device infection.

CONCLUSION

In pacemaker-dependent patients with limited prepectoral and vascular access options, a low lateral thoracic implantation site is a viable alternative to surgical epicardial or femoral pacing systems. This simple implantation technique is a safe and effective option in selected patients who require a single-chamber, dual-chamber, or biventricular pacemaker or implantable cardioverter-defibrillator.

Subpectoral Implantation of Internal Pulse Generators for Deep Brain Stimulation: Technical Note for Improved Cosmetic Outcomes

BACKGROUND: Deep brain stimulation is increasingly used to treat a variety of disorders. As the prevalence of this technology increases, greater demands are placed on neurosurgical practitioners to improve cosmetic results, maximize patient comfort, and minimize complication rates. We have increasingly employed subpectoral implantation of internal pulse generators (IPGs) to improve patient satisfaction.

OBJECTIVE: To determine the complication rates of subpectorally placed IPGs as compared to those placed in a subcutaneous location.

METHODS: We reviewed a series of 301 patients from a single institution. Complication rates including infection, hematoma, and lead fracture were recorded. Rates were compared for subcutaneously and subpectorally located devices.

RESULTS: Of the records reviewed, we found 301 patients who underwent 308 procedures for initial IPG implantation. Of these, 275 were subpectoral IPG implantation, 19 were infraclavicular subcutaneous implantation, and 14 were subcutaneous implantation in the abdomen. A total of 6 IPG pocket infections occurred, 2 subpectoral and 4 infraclavicular subcutaneous. Of the IPG infections, 2 of the infraclavicular subcutaneous devices had associated erosions. Two patients had their devices relocated from a subpectoral pocket to a subcutaneous pocket in the abdomen due to discomfort. Two patients in the subpectoral group suffered from hematoma requiring evacuation. Two patients in the infraclavicular subcutaneous group had lead fracture occur.

CONCLUSIONS: Subpectoral implantation of deep brain stimulation IPGs is a viable alternative with a low complication rate. This technique may offer a lower rate of infection and wound erosion.

Safe and Simplified Salvage Technique for Exposed Implantable Cardiac Electronic Devices under Local Anesthesia

Background

Skin erosion is a dire complication of implantable cardiac pacemakers and defibrillators. Classical treatments involve removal of the entire generator and lead systems, however, these may result in fatal complications. In this study, we present our experience with a simplified salvage technique for exposed implantable cardiac electronic devices (ICEDs) without removing the implanted device, in an attempt to reduce the risks and complication rates associated with this condition.

Methods

The records of 10 patients who experienced direct ICED exposure between January 2012 and December 2015 were retrospectively reviewed. The following surgical procedure was performed in all patients: removal of skin erosion and capsule, creation of a new pocket at least 1.0–1.5 cm inferior to its original position, migration of the ICED to the new pocket, and insertion of closed-suction drainage. Patients with gross local sepsis or septicemia were excluded from this study.

Results

Seven patients had cardiac pacemakers and the other 3 had implantable cardiac defibrillators. The time from primary ICED placement to exposure ranged from 0.3 to 151 months (mean, 29 months. Postoperative follow-up in this series ranged from 8 to 31 months (mean follow-up, 22 months). Among the 10 patients, none presented with any signs of overt infection or cutaneous lesions, except 1 patient with hematoma on postoperative day 5. The hematoma was successfully treated by surgical removal and repositioning of the closed-suction drainage.

Conclusions

Based on our experience, salvage of exposed ICEDs is possible without removing the device in selected patients.

Combined Subpectoral Implantation of Implantable Cardioverter-Defibrillator and Augmentation Mammoplasty in a Young Female Patient

Subcutaneous implantation of a cardiac implantable electronic device is the standard method. Occasionally, subpectoral cardiac implantable electronic device (CIED) implantation via axillary incisions is performed in young female patients for cosmetic purposes. Because subpectoral CIED implantation and augmentation mammoplasty involve the same layer, it is feasible to perform both procedures simultaneously. We report a case of combined subpectoral implantation of an implantable cardioverter-defibrillator and augmentation mammoplasty via the axillary approach in a young female patient with dilated cardiomyopathy and small breasts.

Left axillary pacemaker generator implantation with a direct puncture of the left axillary vein

BACKGROUND

Pacemaker generators are routinely implanted in the anterior chest. However, where to place the generator may need to be considered from the mental, functional, and cosmetic standpoints.

METHODS

In this study, we performed the left axillary pacemaker generator implantation with a direct puncture of the left axillary vein in 40 consecutive patients, and evaluated the late safety and efficacy of this implantation. Complications, changes in the lead sensing, pacing threshold, and impedance were used as safety indexes for a mean follow-up of 3.4 years. In addition, the efficacy was also evaluated by comparing their questionnaire survey results to 119 patients in a control group of anterior chest implantation.

RESULTS

Lead dislodgements were observed in two patients of the experiment group. There were no migrations of generators from the implantation site or abnormal variations in the pacing threshold, lead sensing, or impedance. In the left anterior chest and left axillary groups, 85% and 10% of the patients were worried about an external impact, 80% and 25% were worried about electromagnetic interference, and 68% and 0% answered that the pacemaker implantation site was noticeable, respectively. Apparently, more patients had a sense of security and cosmetic satisfaction with the left axillary implantation.

CONCLUSION

The left axillary generator implantations may reduce the mental burden and cause no safety concerns, and may be performed if functional or cosmetic outcomes are required.