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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 3  |  Issue : 1  |  Page : 87-88

Syncope as a presenting feature of complete extrusion of a unipolar permanent pacemaker


Department of Cardiology, Christian Medical College and Hospital, Ludhiana, Punjab, India

Date of Web Publication22-Dec-2015

Correspondence Address:
Rajneesh Calton
Department of Cardiology, Christian Medical College and Hospital, Ludhiana - 141 008, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2348-3334.172402

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  Abstract 

Complete extrusion of a permanent pacemaker is an extremely rare complication. We report a unique case of a patient presenting with syncopal episodes after complete extrusion of his implanted pacemaker. An 82-year-old gentleman with a history of pacemaker implantation, 6 years back, presented with syncopal episodes and was found to have complete extrusion of his pacemaker out of its pocket. An electrocardiography revealed complete heart block which would revert to paced rhythm when the pulse generator would be pushed back into the pacemaker pocket. Neglecting the pre-extrusion stage, he presented with syncopal episodes after complete extrusion and loss of contact of the unipolar pacemaker with the pacemaker pocket resulting in complete loss of pacing.

Keywords: Pacemaker extrusion, syncope, unipolar pacemaker


How to cite this article:
Mathew C, Calton R. Syncope as a presenting feature of complete extrusion of a unipolar permanent pacemaker. CHRISMED J Health Res 2016;3:87-8

How to cite this URL:
Mathew C, Calton R. Syncope as a presenting feature of complete extrusion of a unipolar permanent pacemaker. CHRISMED J Health Res [serial online] 2016 [cited 2019 Oct 21];3:87-8. Available from: http://www.cjhr.org/text.asp?2016/3/1/87/172402


  Introduction Top


Pacemaker extrusion is a very unusual complication reported in 0.9% cases, with complete extrusion being even rarer.[1],[2] We report a case of patient presenting with syncope due to neglected complete pacemaker extrusion 6 years after implantation.


  Case Report Top


An 82-year-old gentleman with a unipolar permanent pacemaker initially inserted 17 years back, for complete heart block, and with a history of pulse generator replacement 6 years back, presented to the casualty with syncopal episodes for 6 h. Since the last 2 years, he had not been following up at any hospital.

On examination, he was found to have complete extrusion of the single chamber pacemaker, being attached only with a lead [Figure 1] and [Figure 2].
Figure 1: Patient with unipolar pacemaker completely extruded out of its pocket

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Figure 2: Chest X-ray showing the extruded pacemaker (star sign) still attached with an intact lead. The lead is seen with tip in right ventricular apex (arrow sign)

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He revealed that the pacemaker was gradually partially extruding over a period of 2 months but he was asymptomatic and hence, he did not seek any medical attention as he was living alone. He started having symptoms when the pacemaker was completely extruded out of the pocket attached to the lead. On evaluation, he was found to have complete extrusion of the pacemaker out of his pocket which was kept tied to his body with a piece of cloth. Patient did not have fever or signs of infection at the pacemaker site, and his total leukocyte count was normal. An electrocardiography revealed complete heart block with a rate of 30/min which would revert to paced rhythm when the pulse generator would be pushed back into the pacemaker pocket. An emergency temporary pacing was done and patient was started on intravenous antibiotics. Wound cultures sent from the pacemaker site were showing no growth. The pacemaker was disconnected, the wound was surgically debrided, and a new pacemaker pocket was created at the same site. The lead parameters were checked and threshold was 1.4 mV and lead impedance was 794 ohms and was accepted. A new pacemaker was connected to the chronic lead. The wound healed without any complications.


  Discussion Top


This case illustrates a rare and severe neglected form of pacemaker erosion. However, the complete extrusion of the pacemaker generator from the subcutaneous pocket is very rare and risk factors causing skin erosion include inadequate pocket space, local irritation and infection, low socioeconomic status, suppressed patient immunity, anticoagulation therapy, and Type 2 diabetes mellitus.[2],[3]

Two main reasons responsible for pacemaker extrusion are infection and pressure necrosis.[1],[4] While infection usually contributes to extrusion in the acute phase, small pacemaker pocket and pressure necrosis is usually responsible in the long-term phase. The size of the pacemaker as well as lead and connectors (e.g., lead adaptor) in the pocket may lead to increased local tension and pressure necrosis.

Complete pacemaker extrusion is usually preceded by discoloration of thinned skin tissue stretched over the pacemaker.

Here, the patient neglected this stage of pre-extrusion as he was asymptomatic during this stage. He presented with syncopal episodes only after complete extrusion and loss of contact of the unipolar pacemaker with the pacemaker pocket resulting in complete loss of pacing.


  Conclusion Top


This case report highlights the need for proper patient education regarding regular follow-up as well as informing them about potential complications which can occur not only in short-term but in long-term period also. Identification of the pre-extrusion stage of pacemaker with appropriate action is needed to prevent further life threatening complications in long run.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Shapiro M, Hanon S, Schweitzer P. A rare, late complication after automated implantable cardioverter-defibrillator placement. Indian Pacing Electrophysiol J 2004;4:213-6.  Back to cited text no. 1
    
2.
Parsonnet V, Trivedi A. Images in cardiovascular medicine: Pacemaker extrusion. Circulation 2000;102:1192.  Back to cited text no. 2
    
3.
Puri R, Khurana S, Young GD. Complete extrusion of an implantable cardiac defibrillator. Europace 2008;10:173-4.  Back to cited text no. 3
    
4.
Nichev J, Balabanski T. A case of total pacemaker extrusion. Europace 2009;11:670.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2]



 

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  In this article
Abstract
Introduction
Case Report
Discussion
Conclusion
References
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