PM Removed for Now

After 21 days in hospital and 7 procedures since June, my PM is out for while. I dodged a bullet 3 times, avoiding endocarditis and major infection.

I'm left with a gaping wound under my right clavicle because it couldn't be stitched due to tissue necrosis and scarring. My wonderful wife is left with wound care, which includes packing the "pouch" with 2 feet of gauze soaked in Bernell's Solution. The wound is painful, but looks clean actually. It has never shown any outward signs of infection.

I think the Doc wants me to wait 2-3 weeks until my left clavicle area is healed sufficiently to implant a new PM. It's healed well, but feels a bit sore.

Since the first 2 PM's failed and a "re-implant" also failed, I want this one done right.

Since doing things the same way resulted in failure, I told the docs that I want things done differently. They agreed, and will use a different brand PM, which I'm hopeful will be coated. The procedure will be done in the OR, not the cath lab. I will have a different doc and nurses. I was thinking of even wearing a different brand of underwear for the surgery. :)

Both a 72 hour allergy test and many cultures have always shown negative, yet I keep rejecting the PM. The docs are saying that either there is a low level infection, or a slight allergy. That's all it CAN be. So I want every precaution taken to eliminate both eventualities.

In my heart of hearts, I know it's not going to work. The docs are not taking a scientific approach to this. They do hundreds of PM implants in my hospital, and very few fail. So they believe their success rate will somehow rub off on me.

I'm getting discouraged. I hate being without a PM, but I know better than to let them just stick another one in there and hope for the best. It didn't work before, and it won't work in the future unless some proper research is done. I think there are more sophisticated ways of finding infectious organisms than blood cultures, but may be expensive and time consuming.

I intend to ask the doc to find exactly why my PM was rejected so it won't happen again. Is that reasonable, and what would be some questions to ask?

Sorry for long post and venting, Many thanks,,,

9 Comments

Discouraged

by Pookie - 2008-10-12 02:10:57

Hi Bobad.

I'm so sorry to hear you've been put through the ringer. I too would be discouraged and frustrated.

So, you're gonna go at it again! Bravo for you. I'm glad to hear that you will be in the OR and not in a cath lab.

You mention using another brand of pacemaker this time...what did you have before that didn't work? I posted something I found about a pacemaker that is tucked into some kind of antibiotic pouch prior to the insertion...would that be something they might use on you? (I'll send it to you via private messages).

Perhaps this time it will all work out. I certainly understand when you've had so many bad outcomes that you wouldn't put any trust in the upcoming surgery. I too had to go thru 5 operations for my pacemaker...but I kept on going and now all is well. I remember at one point saying to heck with the pacemaker at all...let nature take its course...but then somewheres I gained the strength to go onto surgery #5.

And I think you are correct when you mention finding organisms in blood cultures...everything has a cost associated with it, and unfortunately, money talks. I have found myself in numerous occasions where a test was mentioned (almost offered) then taken back because of the cost!...I mean, why mention it to begin with, only to do nothing. I tend to think that my life is just as valuable as the next person's!

I just hope and pray that you get everything taken care of fast and in a way that makes YOU comfortable, both mentally and physically.

And any question is reasonable!!!!!!!! Ask questions until YOU are satisifed with the anwers. Personally, I think it is your right.

oh...and you're NOT venting. (I take the prize in the venting category!!!)

We are here to support yah!

Good luck and please keep us posted.

Pookie



dear bobad

by jessie - 2008-10-12 11:10:09

boy you have gone the gamut for sure. i am hoping and praying this time it works for you so you can get on with your life. you can vent all you like. we have all had our time venting so don't worry one bit. we just celebrated thanksgiving here but actually to-morrow is the day and we will ahve leftover turkey. i am in canada. your p.m. friend jess

rejection of PM

by dual pacer - 2008-10-13 04:10:16

Hi bobad, maybe a different brand of pacemaker would work, What if they gave you an IV Anti biotic before the in plant? that is what they did before my PM was inserted. Also, do you take antibiotics before going for dental work?? I do not only for the PM but for my aortic valve replacemet. to prevent any infection getting to the weakest area, which for all of us is our heart?? I have a Medtronic and my first one lasted 11 years. this on is fine so far but uncomfortable due to bra and irritation. Tender to touch too. I will keep you in my prayers and keep us posted. Your wife will also need support too. It is hard to be the caretaker. best of luck

patty

PM Brand, Thanksgiving, Leads, No PM

by bobad - 2008-10-13 10:10:39


Hi guys. Many thanks for the support and information!

Pookie, I have a St. Jude PM. I'm ready to change brands just to do something different. Medtronic or whatever doesn't matter to me. My problem is caused by A. An allergy to the PM materials, or B. A low level infection. I'm going to have to get some level of assurance that corrective action has been taken to prevent both.

Jessie, thanks so much for your support and prayers. And happy Thanksgiving to all you Canuks! It's a great holiday, a great tradition, and a great country you guys share.

EFrank, they pulled my leads out each time, and used new leads. The 3rd time they took out my PM, they just irrigated the pocket with Betadine, and re-implanted it. That time the leads were left undisturbed. This time, everything was removed.

1of4, I'm doing OK without the PM. I have SSS, and get a peculiar sequence of arrhythmias. All day long, I just get some PVC's that are bothersome, but harmless. When my heart is in its real funky mode, I get bigeminy PVC's, which triggers tachy, which triggers sudden brady and sometimes a block, which re-boots my heart into sinus rhythm for a while. No funky episodes in the 3 days since my PM was explanted, but I never know when it will occur. I'm taking a minimal dose of beta blocker, which seems to lessen the occurrences of the episodes.

What type of arrhythmia do you have 1of4? They seldom get better, so unless there is better medicine, chances are not too great that you will thrive without your PM. But yea, I know what you mean. Although I worry about my funky episodes, it feels good without that little alien implanted in my chest. :)

PM allergy? Or is it?

by Stepford_Wife - 2008-10-13 11:10:46

Hi bobad.

I picked up this article, while searching the web, wondering what could be causing a pacemaker "rejection. "
Granted, it isn't an updated article, ( 1998, ) but, it is very informative, in the sense that it mentions several different micro-organisms that could cause infection, and how and where these M-Os actually happen to be.
I hope you can get some use out of it, and I hope it helps with solving your " rejection " issue.
It's a bit long, but it could be helpful to others as well.
Good luck, my thoughts are with you.
Take care,

~ Dominique ~

Infection is a serious, potentially life-threatening complication after pacemaker surgery; morbidity and mortality are reported to be high. Its prevention would greatly benefit from a better knowledge of mechanisms involved. Several mechanisms have been advocated, although none has been fully validated. Local perioperative wound contamination is usually described as the major mechanism predisposing to local or systemic pacemaker infection. The presence of a superficial foreign body can predispose to skin erosion or necrosis and also cause infection. Besides, microorganisms can colonize foreign bodies such as pacemaker leads by the hematogenous route. The predictive values of preoperative and operative local bacteriologic flora have not been fully explored; conclusions drawn from small series are elusive.

In this prospective study, 4 patients out of 103 (3.9%) developed infection. Two of them developed bacteremia shown by positive blood cultures (patients 1 and 2), one developed a wound abscess (patient 3), and one a local infection (patient 4). S schleiferi was associated with two of these four cases of infection and was also isolated at the time of pacemaker implantation . The frequency of association of S schleiferi with infections in this series is surprising compared with its low frequency of isolation in the prospective samples (5 out of 267 isolates). Four other cases of pacemaker infection caused by S schleiferi have been reported previously. When analyzing these six cases (two from the present study plus four from the previous study ), the interval between pacemaker implantation and infection varied between 6 weeks and 16 months, with a median of 10 to 12 months. In the present study we have demonstrated by a molecular method that the strain associated with pacemaker infection and present in blood cultures was already present in the operative sample at the time of pacemaker insertion. This supports a previous hypothesis that delayed infections caused by CNS are due to local bacterial contamination acquired at the time of surgery. This also strongly suggests that infection is likely to begin at the pacemaker pocket and extend down the lead. Furthermore, strains of S schleiferi isolated from our two patients displayed different ribotypes assessing the lack of pathogenic link between them and allowing exclusion of a specific operator contamination. Besides pacemaker infections, S schleiferi has been associated with other human conditions such as infections of wounds, hip prostheses or vascular devices, brain empyema, and bacteremia, but the frequency of these infections is extremely low compared with those caused by other species of staphylococci such as S aureus or S epidermidis. However, S schleiferi may be misidentified as S aureus because both species express a fibrinogen affinity factor (clumping factor), a characteristic frequently used to identify S aureus. Hence the actual responsibility of S schleiferi in human infections especially on biomaterials may have been underestimated as coagulase-negative staphylococci from infected materials are not systematically identified at the species level senso stricto by all laboratories. Moreover, bacteriologic cultures from pacemaker skin erosion are not currently done if signs of infection are not patent. The peculiar association of S schleiferi with pacemaker infection may reflect the expression by this species of specific virulence factors such as surface receptors that are presently unknown.

Although a local antisepsis was applied, several organisms (mostly staphylococci) were cultured in the pocket and over the generator before suturing. This phenomenon plays an important role, suggesting a local contamination with the staphylococci present within the skin appendages (including hairs, sebaceous glands, and sweat glands), which might contaminate the wound margins during surgical procedure, probably during the pocket achievement. The present study also showed that S epidermidis, although representing the majority of strains isolated at the time of implantation, was very rarely responsible for subsequent infection. In a previous study, Ramsdale et al took preoperative microbiologic specimens in more than 470 patients, but the results of preoperative culture were not found to be predictive of subsequent infection. In their series, six patients had pathogens over the skin before surgery (among which five were S aureus), but none of the six patients developed infection. No data are available concerning bacteriologic findings in the pacemaker pocket and wound margins in their study. Bacteriologic examinations were also performed by Bluhm et al. Samples were obtained from tissue fluid of the pacemaker pocket 1 day after surgery. Out of 34 patients not receiving an antibiotic prophylaxis regimen, cultures were positive in 10 but none developed subsequent infection. Another study from the same authors led to the same conclusions. Only one study was made to predict the causative organism in postoperative infection. Specimens for culture were taken from the nose, the throat, and from the wound margins at the end of the operation. A needle aspiration was performed from the pacemaker pocket in each patient with suspected infection. Identity of a strain of S aureus isolated from the nose before surgery to that collected at the time of infection from a wound culture was demonstrated by phage typing, with no molecular marker being available in 1983. For the other seven patients in their series, no definitive conclusion could be drawn by analysis of the preoperative and postoperative microbiologic flora. In contrast, our prospective study evidenced the pathogenic role of the preaxillary flora, notably that of S schleiferi, in early and late pacemaker infections.

Another important finding deals with pacemaker erosion. Our results support the hypothesis that apparently clinical pacemaker erosion without obvious local infection may be primarily caused by infection (two of three patients in our series); systematic local sampling and blood cultures should be recommended in this setting. Indeed, specific microorganisms such as S schleiferi or S epidermidis can be responsible for nosocomial infections, especially in the presence of foreign bodies.

Conclusions
Our study shows that numerous strains of organisms are present in the pacemaker pocket at the time of implantation despite careful preoperative preparation of the skin, suggesting their subcutaneous origin. They are very rarely responsible for subsequent infection. Among these organisms, S schleiferi appears to play a particular and so far underestimated role in infectious colonization of implanted biomaterials and should be regarded as an important opportunistic pathogen. This study gives new insights into the pathogenesis of infections secondary to pacemaker infections and strongly supports the hypothesis that pacemaker-related infections are mainly due to local contamination during implantation. These data equally support the hypothesis that pacemaker erosion can be caused by primary infection. Our findings further raise the question of a likely benefit of antibiotic prophylaxis in this setting to prevent subsequent major infections.

Same leads?

by ElectricFrank - 2008-10-13 12:10:32

Have they reused the same leads for each pacemaker? It is possible that the lead connections are harboring an infection. Just a thought.

frank

How are you dong without the pacer?

by 1of4kids - 2008-10-13 12:10:49

bobad,
I am just wondering how you doing without the pacer? I am thinking of not getting the replacement once this one dies since I have yet find a doctor who will tell me I do indeed need it. Do you find it difficult to do some things without the pacemaker or you feel no difference?

PM Allergy

by 60bpm - 2008-10-14 09:10:00

Hi Bob,
Just read your post and thought I'd drop you a line. It's been a month since my PM replacement surgery. I am beginning to have more and more pain at my PM site radiating to my left arm pit. The EP said it would take longer to heal with the Dacron Pouch, but it seems like it's getting worse not better.
Remember our conversation about Dr. David Hayes at the Mayo Clinic in Rochester? I have tried to contact him to no avail, despite that he is still listed as the head of Cardiology there. Do you think there is any chance your EP can attempt to reach him concerning the coating procedure he used on two former patients presenting with allergic symtoms, presumably titanium. I also am in the process of validating my metal allergies using Melisa Diagnostics. This is done via blood test - not patch testing which is consequently not reliable.
I know we've both had some rough months since June but we've gotta keep fighten. The alternative isn't too appealing :) Please let me know if you get anywhere if you choose to pursue contacting Dr. Hayes.
In the meantime, I'll keep you close in thought and prayer. Warm Regards, Diane

Thanks Dual and Stepford

by bobad - 2008-10-14 09:10:12


for the info and nice replies.

Stepford, not surprising to me, I have already read that article. While healing up, I've been spending 2-3 hours a day scouring the Web for articles on PM rejection and infection. But it was a good article, and I read it again. I think it's amazing that more people don't get infection or rejection due to bare metal in contact with tissue, which is medieval medicine. Repeating how my problem originally started, my PM incision was healed perfectly in 1 week, and was perfect for 3 months. Then it suddenly started turning red and getting water blisters at the incision. It could happen to anyone, though it seems to be rare.

Dual, I received a course of IV antibiotics before and after getting the original PM.

I bet your PM is tender because it's bare metal, which can short out nerves and cause tenderness and even muscle spasms. Some people have fewer nerves in the chest muscle area and feel less pain, others have more nerves and experience more pain. Pain has never been a problem with me, but obviously is with you. Thanks for the prayers, and best of luck to you.

You know you're wired when...

You run like the bionic man.

Member Quotes

I'm 35 and got my pacemaker a little over a year ago. It definitely is not a burden to me. In fact, I have more energy (which my husband enjoys), can do more things with my kids and have weight because of having the energy.