Congenital AV-block, thrombophilia and pacemaker malfunction, a nightmare association

Introduction: Cardiac implantable electronic devices are gaining increasing importance in the treatment of many cardiac conditions, therefore the implantation rates increased continuously in the last decade. This results in a higher infection prevalence, despite the use of appropriate antimicrobial prophylaxis. Surgical site infection is the most common cause of implantable device-related infections. It usually requires removal of both the device and pacing leads, which brings a significant financial burden and considerable risk of further life threatening complications for the patient.
Case presentation: We present the case of a 42 year old diabetic male, smoker, previously diagnosed with thrombophilia (personal history of recurrent stroke and deep vein thrombosis), who in 2007 received a single lead pacemaker for congenital grade II AV block. He was admitted in May 2017 for battery depletion. On admission a high pacing threshold is registered for the ventricular lead. During the battery replacement procedure, the lead extraction attempt failed (passive fixation) and therefore the ventricular lead was abandoned. Another dual chamber pacemaker was implanted using the same left subclavian pouch. Early after the procedure the patient is started on subcutaneous Enoxaparine (previous thromboembolic events) and Dabigatran afterwards. 8 days after the index procedure he develops a pouch hematoma with superimposed infection (fever, pain and tenderness at the level of the pouch and elevated inflammatory markers). After 3 weeks of antibiotics the device is removed and a new dual chamber pacemaker is implanted using the contralateral venous acces, without complications. Surgical resections of the proximal end of the previously abandoned lead is performed and the remaining portion is burried in the left subclavian region. Two months later (July 2017) the patient is readmitted with neuropathic pain in the left shoulder and subclavian region, probably caused by lesions of brachial nerv endings. With the help of plastic surgeons on site, hooding of the proximal end of the abandoned lead is performed, coupled with neurorrhaphy of the lateral branch of the left subclavian nerve. Shortly afterwards migration of the lead end into the superior vena cava is noted. Percutaneous extraction of the abandoned lead is decided, which was done at Floreasca Hospital in Bucharest, without further complications; two weeks later though the patient exhibits a novel thrombotic event (thrombosis of the right internal jugular vein), which partially resolved after antico-agulants and anti-inflammatory medication. Presently there are no local signs of infection or inflammation at the level of the pacemaker pouch, the device is working properly but the neuropathic pain in the territory of the left brachial nerve persists.
Case particularity: T he occurrence of multiple early and late permanent pacing complications in a patient with congenital AV block and associated thrombophilia.
Conclusion: The afore mentioned case is a testimony to the problematic management of an atypical patient in whom the risk of bleeding and infection intertwines with thrombotic events and unforeseen technical problems, ultimately requiring a multidisciplinary app-roach.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
ESC search engine
CODE: 379
CME Credits: 10 (Romanian College of Physicians)