Unmasking the Chameleon: Navigating Complications in Pacemaker Implantations - A Case Report.

An 84-year-old male patient presented to the emergency room with progressive redness and swelling in the left pectoral area and left arm. This occurred three weeks after a dual chamber pacemaker (PM) implantation for sick sinus syndrome and loop recorder explantation in an outpatient clinic. The symptoms started a few days post-procedure in the PM pocket area and spread subsequently in the left arm. Additionally, the patient observed linear redness on the right lower abdomen and left groin. There were no symptoms of fever, shortness of breath, or allergies.

Clinical examination revealed a tender, hardened swelling in the left chest with pronounced skin redness in the left pectoral and arm areas, along with spreading redness in both groin areas (see Figure 1). Laboratory results showed slightly elevated C-reactive protein (CRP) levels, but other infection parameters were within normal range. Blood cultures were taken, and due to suspicion of infection, antibiotic therapy with ampicillin/sulbactam was initiated. Ultrasound imaging showed no signs of thrombosis in the left arm. However, findings suggested a possible hematoma/seroma or abscess. A CT scan and X-ray imaging showed no further pathologies with correct placement of the PM. PM interrogation indicated normal system function, and the PM was programmed to a minimal pacing frequency of 30 bpm to assess the need for PM therapy and plan further steps. Subsequent blood cultures remained sterile.

Despite antibiotic therapy and topic anti-inflammatory therapy, there was no clinical improvement. Since an infection of the PM-System could not fully be excluded, we decided to explant the device and leads. The procedure was performed without any complications. Monitoring and follow-up PM interrogation indicated no need for further pacing therapy. Intraoperatively, various samples were taken and sent for further microbiological and histopathological examination. Histologically examination revealed relatively extensive necroses in the subcutaneous adipose tissue with signs of early organization. Furthermore, surgical suture material was identified, surrounded by giant cells and inflammatory reaction. Thus, extensive fat tissue necroses and signs of a resorptive mesenchymal reaction are evident. 

Three months post-explantation, follow-up showed nearly complete regression of the cutaneous manifestations. However, redness persisted at the site of the explanted loop recorder, possibly due to further residual suture material, which was used during explantation (s. figure 2). A revision of the wound is planned.

Conclusion:

Ultimately, the symptoms of our patient were explained by a reaction to the surgical suture material. This case underscores the importance of strict criteria for pacemaker implantations and demonstrates that complications can present in varied and unexpected ways, prompting the need for out-of-the-box thinking.