Complications of Cardiac Resynchronization Therapy: Infection

History

An 86-year-old gentleman was seen in the clinic for concerns regarding drainage at the site of his cardiac device on the left chest wall. His history was significant for ischemic heart disease and sinus node dysfunction, for which he had undergone pacemaker placement 2 years previously. At that time, his ejection fraction was estimated to be 38%. More recently, he was found to have New York Heart Association class III symptoms of congestive heart failure despite aggressive medical management. His ejection fraction was found to be 30%, and therefore his device was upgraded to a cardiac resynchronization therapy defibrillator (CRT-D) 6 weeks before presentation. At the time of this procedure, the old right ventricular pacing lead was removed but the chronic atrial lead was left in place. A routine recheck revealed the patient’s P wave to be significantly reduced, at 0.2 mV. Device interrogation confirmed that there was no capture on the atrial lead, and therefore he underwent atrial lead revision 3 weeks before presentation. This procedure was complicated by a postoperative hematoma at the surgical site that was managed conservatively. A few days after the procedure, he noticed pain, redness, and drainage from the device pocket in the left chest wall ( Figure 35-1 ) and sought further evaluation at the clinic.

The review of systems in this patient was negative for fever or chills. He did have some fatigue and worsening shortness of breath but did not report chest pain or sputum production.

His other relevant comorbidities included prostate and laryngeal cancer, hypertension, hyperlipidemia, and iron deficiency anemia without an obvious source of bleeding. He had undergone a coronary artery bypass graft in 1994.

Current Medications

The patient was taking clopidogrel 75 mg daily, ferrous sulfate 325 mg (65 mg iron) daily, ramipril 5 mg daily, metoprolol 25 mg daily, isosorbide mononitrate 30 mg daily, furosemide 20 mg daily, niacin 1000 mg daily, simvastatin 40 mg daily, and aspirin 81 mg daily.

Current Symptoms

The patient was experiencing erythema, pain, and drainage at the site of device pocket in the left chest wall.

Physical Examination

• BP/HR: 118/58 mm Hg/68 bpm

• Height/weight: 167 cm/85 kg

• Neck veins: Jugular vein distention up to the angle of the mandible

• Lungs/chest: Bilaterally clear to auscultation

• Heart: Normal first heart sound (S ₁ ) and second heart sound (S ₂ ) with grade 3/6 systolic ejection murmur best heard at the base of the heart; skin over the left chest at the device pocket site was erythematous and warm, with purulent discharge from the pocket site; 1 cm dehiscence of surgical incision

• Abdomen: Nondistended, soft and nontender, bowel sounds normal

• Extremities: No large joint swelling, redness, or tenderness; 2+ pitting edema

Laboratory Data

• Hemoglobin: 8.8 g/dL (normal range: 13.5-17.5 g/dL)

• Hematocrit/packed cell volume: 38.1% (normal range: 38.8%-50%)

• Mean corpuscular volume: 106.8 fL (normal range: 81.2-95.1 fL)

• Platelet count: 165 × 10 ³ /µL (normal range: 150-450 × 10 ⁹ /L)

• Sodium: 140 mmol/L (normal range: 135-145 mmol/L)

• Potassium: 4.5 mmol/L (normal range: 3.6-5.2 mmol/L)

• Creatinine: 2.1 mg/dL (normal range: 0.8-1.3 mg/dL)

• Blood urea nitrogen: 49 mg/dL (normal range: 8-24 mg/dL)

• Leukocytes: 15.8 × 10 ⁹ /L (normal range: 3.5-10.5 × 10 ⁹ /L)

Electrocardiogram