Department of Cardiovascular Surgery, University Medical Center Ljubljana, Zaloska 7, 1000, Ljubljana, Slovenia.
Clinical Institute of Radiology, University Medical Center Ljubljana, Zaloska 7, 1000, Ljubljana, Slovenia.
J Cardiothorac Surg. 2020 Sep 16;15(1):258. doi: 10.1186/s13019-020-01303-y.
Pocket-related complications following the implantation of cardiovascular implantable electronic devices primarily include pocket hematoma, infection, skin erosion or decubitus, device migration, and Twiddler's syndrome, with other pathologies such as nerve impairment or bone lesions being extremely rarely encountered. We report a case of a 20-year old asthenic, non-athlete female patient presenting with a device-generated fracture of the second rib several months after sub-muscular permanent pacemaker implantation due to repeated bilateral pre-pectoral pocket infections.
A 20-year old female patient was readmitted to our institution 9 months following sub-pectoral implantation of a permanent pacemaker, complaining of severe pocket-related pain, which arose spontaneously in the absence of direct trauma, intense physical activity or vigorous coughing, and was associated with normal day-to-day activity. To rule out a pacemaker re-infection, a native computed tomography and a positron emission tomography-computed tomography of the thorax were performed. Both modalities excluded an infection but showed a healing fracture and a focus of enhanced metabolic activity in the anterolateral part of the right second rib, indicating a non-traumatic or stress fracture of the bone. Consequently, a complete extraction of the pulse generator and both leads was performed and the smallest available single-chamber pulse generator with a single atrial electrode was implanted in the sub-fascial, pre-muscular pocket in the now recovered and uninfected left subclavicular region, alleviating patient's severe pain symptoms and significantly enhancing her quality of life.
In the absence of direct trauma, intense physical activity or vigorous coughing, we assume that in this asthenic girl a normal day-to-day motion of the right shoulder has persistently forced the sub-muscularly placed pulse generator toward thoracic wall, putting increased repetitive pressure force on the underlying bones, finally causing a fatigue stress fracture of the second rib. In asthenic phenotype patients with small thorax and short subclavicular distance, a sub-muscular pacemaker implantation can potentially cause unique and unexpected pocket-related adverse events necessitating advanced diagnostics and timely treatment.
心血管植入式电子设备（CIED）植入后与囊袋相关的并发症主要包括囊袋血肿、感染、皮肤侵蚀或压疮、器械移位和 Twiddler 综合征，而神经损伤或骨病变等其他病变极为罕见。我们报告了一例 20 岁瘦弱、非运动员女性患者，在皮下永久性起搏器植入后数月出现第二肋骨设备性骨折，原因是双侧胸前囊袋反复感染。
一名 20 岁女性患者在皮下植入永久性起搏器 9 个月后因严重囊袋相关疼痛再次入院，疼痛自发性出现，无直接创伤、剧烈体力活动或剧烈咳嗽，且与日常活动无关。为排除起搏器再感染，进行了胸部 CT 和正电子发射断层扫描（PET-CT）检查。两种方式均排除了感染，但显示出愈合性骨折和右第二肋骨前外侧代谢活性增强的焦点，提示为非创伤性或应激性骨折。因此，进行了脉冲发生器和两根导线的完全取出，并在现已恢复且未感染的左锁骨下区域的皮下、前肌肉囊中植入了最小的单腔脉冲发生器和单个心房电极，缓解了患者的严重疼痛症状，并显著提高了生活质量。
在没有直接创伤、剧烈体力活动或剧烈咳嗽的情况下，我们假设在这位瘦弱女孩中，右肩部的日常正常运动持续迫使皮下放置的脉冲发生器向胸壁移动，对下面的骨头施加了增加的重复压力，最终导致第二肋骨的疲劳性应力性骨折。在瘦弱体型患者胸廓小、锁骨下距离短的情况下，皮下起搏器植入可能会导致独特且意外的囊袋相关不良事件，需要进行先进的诊断和及时治疗。
