Response to Letter to the Editor: A Case of Gold-coated Pacemaker for Pacemaker Allergy

DOI: 10.19102/icrm.2014.050602

ANIL GOLI, MD, FACC, FHRS, SUNIL SHROFF, MD, FACC, FHRS, MOHAMMED N. OSMAN, MD, FACC, FHRS and JOHN LUCKE, MD, FACS

Charles George VA Medical Center, Asheville, NC

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Dear Editor:

We respectfully disagree with Dr. Cooper's assessment of our patient who had a pacemaker allergy.^1,2 The patient was treated by an experienced operator who has a high patient volume, is versatile in lead extraction procedures, and is aware of the common presentation of pocket infections.

When learning about the identification of disease, medical students are advised, “When you hear hoofbeats, think horses, not zebras” - a quote attributed to Theodore Woodward of the University of Maryland School of Medicine. This aphorism trains physicians to first consider the most common disease. However, there are “zebras” in medicine: rarer diseases that unambiguously exist. If hoofbeats always could be attributed to horses, this fine journal would not need to exist. Although it is wise for physicians first to consider “horses,” ignoring the presence of “zebras” may be detrimental to the patient.

Allergic reaction to implants are rare, but literature search for the past 35 years showed a minimum 30 reported cases of hypersensitivity to pacemaker components causing adverse reactions manifesting in the skin. Reports of pacemaker hypersensitivity may be rare because of misdiagnosis as infection.³ In contrast, the frequency of infectious complications is 1% to 2% (0.13% to 19.9% for patients who have an intra-abdominal implant).⁴

Our patient had repeated wound evaluation because of failure of the incision to heal. The minimal erythema that was limited to the incisional edges supported the impression of inflammation (Figure 1).¹ Although the patient had wound dehiscence, he did not have pocket swelling or discharge, skin puckering, generalized inflammatory changes, or wound slough, in contrast with clinical findings typically observed with infected pacemaker sites (Figure 2).

Implanting a titanium-encased pacemaker at another site, as suggested by Dr. Cooper, would not have resolved our patient's problem. A similar titanium implant on the contralateral side may have caused a similar outcome with nonhealing and erosion and might have placed the patient's life at risk. Instead, the patient had normal healing and good outcome by changing to a different pulse generator with gold casing and insulation of the lead. Furthermore, we typically avoid pacemaker implant at the persistent left superior vena cava side in healthy and functional patients because of increased associated risks of atrial fibrillation, ectopic atrial activity, and future need for ablation. Implants at the persistent superior vena cava are considered in elderly patients who have poor functional reserve and who would not be candidates for ablative treatment for future atrial arrhythmias.

Device erosion without other classic local signs of infection should be investigated diligently because of associated high risk of morbidity and mortality. It may be difficult to detect allergic reactions, and testing for titanium allergy may be unreliable.⁵ In addition to pacemaker component allergy, other rare causes of wound problems at pacemaker sites may include alpha1-antitrypsin deficiency and suture material allergy.

References

1. Goli A, Shroff S, Osman MN, Lucke J. A case of gold-coated pacemaker for pacemaker allergy. Journal of Innovations in Cardiac Rhythm Management 2012; 3:944–947. [CrossRef]
2. Cooper JM. Letter to the editor: a case of gold-coated pacemaker for pacemaker allergy. Journal of Innovations in Cardiac Rhythm Management 2012; 4:1134. [CrossRef]
3. Andrews ID, Scheinman P. Systemic hypersensitivity reaction (without cutaneous manifestations) to an implantable cardioverter-defibrillator. Dermatitis 2011; 22:161–164. [CrossRef] [PubMed]
4. Hercé B, Nazeyrollas P, Lesaffre F, et al. Risk factors for infection of implantable cardiac devices: data from a registry of 2496 patients. Europace 2013;15:66–70. doi: 10.1093/europace/eus284. [CrossRef] [PubMed]
5. Déry JP, Gilbert M, O′Hara G, et al. Pacemaker contact sensitivity: case report and review of the literature. Pacing Clin Electrophysiology 2002; 25:863–865. [CrossRef] [PubMed]