Original article
Adult cardiac
Salvage of Pacemakers and Automatic Implantable Cardioverter-Defibrillators Using Dermis Grafts

https://doi.org/10.1016/j.athoracsur.2010.10.004Get rights and content

Background

Thin patients with thoracic pacemakers and automatic implantable cardioverter-defibrillators often have minimal tissue over the devices, with erosion through the surface a major concern. This erosion can lead to device infection and need for removal, or primary device infection can, in turn, lead to erosion. Even worse is exposure and infection of the leads to the heart, with fatalities having occurred. Pressure symptoms, as with shoulder seatbelt straps, can occur, and the visible deformity may be objectionable.

Methods

To correct these problems without device removal, we used a novel surgical approach. Thirteen patients had 15 grafts, of either the acellular dermal graft AlloDerm (LifeCell Corp, Branchburg, NJ [n = 13 for threatened exposure or pressure symptoms, including two repeats]) or autogenous dermis (n = 2 for existing open wounds with chronic drainage) placed over the devices.

Results

After all graft procedures, there was no skin breakdown; exposure and extrusion were completely prevented. Follow-up was 3 to 68 months (mean 36.8). The 2 open wound patients treated with dermis autografts had no recurrence of wound breakdown. Most patients with pressure symptoms had reduction in tenderness and pain. Patients liked the visible softening of the device contour, but not the subtly increased forward projection. The only immediate complication was one rapidly expanding hematoma leading to graft removal. One late complication was a mild infection, treated successfully.

Conclusions

Acellular human dermal allografts, or live dermis autografts, provided significant protection over cardiac pacing devices in 13 patients with 15 grafts, with no subsequent surface exposures or extrusions.

Section snippets

Patients and Methods

This study was Institutional Review Board approved, and was Health Insurance Portability and Accountability Act compliant. All patients for surgery were referred from cardiologists. The primary impetus for referral was thin skin with concern about impending implant exposure and infection or pressure symptoms (n = 11), or already existing open wounds with chronic drainage (n = 2). Based on the cardiologists' experience, skin appearance in 3 patients predicted immediate skin breakdown and device

Results

In all graft procedures, there was no postoperative skin breakdown or wound infection. Exposure and extrusion were completely prevented (Table 1, Fig 1, Fig 2, Fig 3). The 2 autografted patients with preoperative open wounds and chronic drainage had no recurrence of infection or drainage. Follow-up from first surgery ranged from 3 to 68 months (mean 36.8).

Early in the series, 2 patients had repeat grafts at a second operation. In both, at surgery, the graft was visible, adherent to native

Comment

Skin erosion leading to cardiac pacing device exposure is a serious complication. Infection usually occurs, and implants can extrude. Or infection can first occur, and lead to erosion. Tsai and associates [2] studied 72 patients with infected implants and found that 42% developed erosion. Harcombe and associates [3] reported that the majority of late complications after pacemaker implantation or replacement were due to erosion and infection. At our institution with a large cardiology practice,

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