Pacemakers pocket erosion

Pacemaker pocket erosion continues to be a problem (Fig. 4.104). This is best avoided by creating a pacemaker pocket that has maximum optimal tissue thickness. Occasionally, in extremely asthenic individuals, subpectorahs major muscle pulse generator placement should be considered to afford optimal tissue thickness. Patients can also present with preerosion secondary to pressure necrosis of the overlying tissue. Such situations represent a quasiemergency if one is to avoid complete erosion and wound infection. The patient should be reoperated, the old pocket abandoned, and new pacemaker pocket created away from the involved site. Sutton and Bourgeois incidence of pacemaker pocket complications are shown in Table 4.25 (17). 

Necessary conditions comprise the second broad category of endocardial lead removal indications. These generally represent situations in which a lead is removed to directly prevent the development of a potential life-threatening problem. Examples of necessary indications are pacemaker pocket infection, chronic draining sinuses, erosions, venous thromboses, lead migration, device-device interference, and the necessity for lead replacement in the case of supernumerary leads in the setting of venous thrombosis. 

The pacemaker pocket may be placed either in the prepectoral fascia or sub-pectorally. The subpectoral approach has the advantage of a better cosmetic resnlt, and a lower likelihood of erosion. The latter issue is particularly important in patients with little or no subcntaneons tissne or who are very small. It has the disadvantage of being somewhat more difficult to enter when the pulse generator needs to be replaced, bnt experienced pacemaker implanters find that this is not a significant impediment. 

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