Pacemaker Extrusion: A Rare Clinical Problem Mainly in Elderly Adults

To the Editor: The elderly population is the most rapidly growing population in developed countries, increasing the number of individuals receiving permanent pacemakers. Herein is described a case of total pacemaker extrusion without prior reported symptoms. A 78-year-old man with a history of dual chamber (DDD-R) pacemaker implantation 7 years before presented to the outpatient cardiology clinic because of total extrusion of a normally functioning pacemaker. He had had no complaints until that morning, when he noticed that his pacemaker generator had appeared through the skin (Figure 1). He had had the generator replaced 2 years before through an incision site below the right clavicle. He had no systemic signs of infection, and wound cultures were negative. He was hospitalized, and the pacemaker was removed and a new pacemaker placed on the other side. Because disorders of impulse generation and conduction are more common in elderly than in younger adults, the number of elderly adults treated with pacemakers or automated implantable cardioverter-defibrillators (AICDs) is rapidly increasing. Octogenarians are reported to account for one-third of total pacemaker implantations, and the average age of pacemaker recipients is 75 ± 10.1, 2 Most studies conclude that elderly adults are at greater risk than younger individuals of peri-implant complications such as lead dislodgement and pneumothorax,3 although data regarding late complications of pacemaker implantation in this population are scarce. As a late complication occurring years after pacemaker implantation, pacemaker erosion is uncommon and is reported in 0.9% of individuals treated with pacemakers or AICDs.4 It is demonstrated to be due to a small or superficial subcutaneous pacemaker pocket or local infection. Although the exact rate of pacemaker extrusion in this population is not known, elderly adults with predisposing factors such as a thin subcutaneous fat layer, fragile skin tissue, depressed immunity, and cognitive impairment are particularly vulnerable to this complication.5 Pacemaker erosion may be treated locally by surgical revision of the pocket without removal of the device. If left untreated, total extrusion of the generator may occur. In the case of total extrusion of the generator, the system is usually considered to be contaminated, and the device and the leads are extracted, with replacement of a new system at a different site.6 Although individuals commonly recognize thinning of the skin and discomfort due to impending extrusion, it may not cause any symptoms, as in this individual. The revision operation of the generator in this individual had been done through the same incision, which contributed to the process. This case highlights the need for frequent follow-up visits in elderly adults with pacemakers—even those without complaints. Early recognition and proper management of individuals experiencing device extrusion is essential to avoid potentially serious consequences. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Both authors contributed equally to the paper. Sponsor's Role: There were no sponsors involved in the process.