Kassa Krisztian Istvan, Som Zoltan, Foldesi Csaba, Kardos Attila
Gottsegen National Cardiovascular Center, Budapest, Hungary; Semmelweis University, Doctoral School, Budapest, Hungary.
Gottsegen National Cardiovascular Center, Budapest, Hungary.
Int J Surg Case Rep. 2025 Aug;133:111610. doi: 10.1016/j.ijscr.2025.111610. Epub 2025 Jul 9.
Adults with congenital heart disease (ACHD) often rely on long-term cardiac pacemaker therapy, which can lead to late complications. This case highlights the management of pacemaker lead decubitus in a patient with repaired Tetralogy of Fallot (TOF).
We report the case of a 71-year-old woman with advanced skin erosion over her pacemaker site. She underwent surgical repair of Tetralogy of Fallot in 1967. In 1977, she was diagnosed with complete heart block and received an abdominal epicardial VVI pacemaker. In 1996, skin perforation occurred at the generator site, leading to its removal and implantation of a transvenous VVI pacemaker from the right infraclavicular region. Due to pacemaker syndrome, an upgrade to a DDD system was performed in 2004. Generator replacements followed in 2012 and 2023. At the time of admission, the patient was clinically stable with no signs of systemic infection. Laboratory tests and inflammatory markers were normal. Transthoracic echocardiography revealed typical postoperative TOF anatomy, preserved left ventricular function, and mild mitral regurgitation. Transesophageal echocardiography showed no vegetations on the leads or valves. CT angiography confirmed patent venous access. With cardiothoracic and vascular surgical backup, we performed percutaneous extraction of the DDD pacemaker system without complications. As the patient was pacemaker-dependent, a temporary active fixation lead was placed via the left subclavian vein and connected to an external generator. After five days of negative blood cultures, we implanted a leadless VDD-pacemaker. The patient recovered uneventfully and was discharged the following day in good condition.
In cases of device erosion or lead decubitus, complete removal of all pacemaker hardware is mandatory to prevent or treat potential infections. For patients who are pacemaker dependent, temporary pacing using an active fixation lead connected to an external generator is a practical bridge while diagnostic evaluation and definitive planning are underway. In this case, implantation of a leadless pacemaker with AV-synchrony offered a safe and effective long-term solution.
Our report underscores the importance of individualized pacing strategies in ACHD patients. Leadless pacemakers offer a promising alternative for patients requiring long-term pacing to eliminate the traditional complications of transvenous devices.
患有先天性心脏病的成年人（ACHD）常常依赖长期心脏起搏器治疗，这可能导致晚期并发症。本病例突出了法洛四联症（TOF）修复术后患者起搏器导线移位的处理。
我们报告了一名71岁女性患者，其起搏器部位出现严重皮肤糜烂。她于1967年接受了法洛四联症的外科修复手术。1977年，她被诊断为完全性心脏传导阻滞，并接受了腹部心外膜VVI起搏器植入。1996年，发生器部位发生皮肤穿孔，导致其被移除，并从右锁骨下区域植入了经静脉VVI起搏器。由于起搏器综合征，2004年升级为DDD系统。2012年和2023年进行了发生器更换。入院时，患者临床稳定，无全身感染迹象。实验室检查和炎症指标正常。经胸超声心动图显示典型的法洛四联症术后解剖结构，左心室功能保留，轻度二尖瓣反流。经食管超声心动图显示导线或瓣膜上无赘生物。CT血管造影证实静脉通路通畅。在心胸外科和血管外科的支持下，我们经皮取出了DDD起搏器系统，无并发症发生。由于患者依赖起搏器，通过左锁骨下静脉放置了一根临时主动固定导线，并连接到外部发生器。在连续五天血培养阴性后，我们植入了无导线VDD起搏器。患者恢复顺利，次日状况良好出院。
在发生装置侵蚀或导线移位的情况下，必须彻底移除所有起搏器硬件，以预防或治疗潜在感染。对于依赖起搏器的患者，在进行诊断评估和明确治疗方案时，使用连接到外部发生器的主动固定导线进行临时起搏是一种切实可行的过渡方法。在本病例中，植入具有房室同步功能的无导线起搏器提供了一种安全有效的长期解决方案。
我们的报告强调了ACHD患者个体化起搏策略的重要性。无导线起搏器为需要长期起搏的患者提供了一个有前景的替代方案，可消除经静脉装置的传统并发症。
