“Shrink-Wrapped” Permanent Pacemaker
An 81-year-old woman originally underwent permanent pacemaker placement in 1994 for symptomatic bradycardia in the setting of respiratory distress. When her device was found to be at the elective replacement interval, she was referred for pacemaker generator replacement. She had been treated with high-dose oral corticosteroids for severe chronic obstructive pulmonary disease for several years and had extremely thin skin and subcutaneous tissues. As seen in Figure 1, her skin appeared “shrink-wrapped” onto the pacemaker generator and extrathoracic leads. We felt that routine generator exchange would be impossible, and that skin erosion was imminent. In the electrophysiology suite, the skin and superficial tissues overlying the generator and leads were resected. Sensing and pacing thresholds of the chronic leads were found to be within acceptable limits. A new pocket was formed under the pectoralis muscle, with access via the infraclavicular border. The new device, leads, and suture sleeves were placed in the new pocket. Figure 2 shows the patient at a clinic visit 9 days after the procedure.