Cardiac Rhythm Management
Articles Articles 2014 May

Self-Induced Pacemaker Mutilation 3 Months after Implant

1RAFFAELE CORBISIERO, MD, FACC, 1MATTHEW LEVY, DO, 1REBECCA ARMBRUSTER, DO and 2DAVID MULLER, RN

1 Deborah Heart & Lung Center, Browns Mills, NJ, USA
2 St. Jude Medical, St. Paul, MN, USA

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David Muller discloses he is an employee of St. Jude Medical.
Manuscript received March 14, 2014, final version accepted March 24, 2014.

Address correspondence to: Raffaele Corbisiero MD, FACC, Deborah Heart & Lung Center, 200 Trenton Road, Browns Mills, NJ 08015, USA. E-mail: corbisieror@deborah.org

Case presentation

We present a 58-year-old male with past medical history significant for hypertension, chronic paranoid schizophrenia, dyslipidemia, Tourette's syndrome, and heart block, for which he had recently undergone implantation of a dual-chamber Accent DR model 2210 (St. Jude Medical, Sylmar, CA) with two model 1688 leads (St. Jude Medical, Sylmar, CA) at a different facility 3 months prior to this admission. Initially, the patient became distressed at home and notified authorities of suicidal thoughts which consisted of disabling his pacemaker, at which time he was evaluated by emergency medical services.

The patient was brought to a nearby hospital and due to his tenuous mental status, as well as hemodynamic compromise, was subsequently admitted. At that time, the patient was noted to be in complete heart block despite his implantable pacemaker. The patient was disorganized in his thoughts and was unable to provide the specific implement he had used to inflict the damage. He was treated in the ICU where he had been restrained for several days to prevent further self-inflicted harm while being maintained on intravenous isoproterenol for heart rate support.

At that time, the patient was transferred to our facility for further treatment and management of his pacemaker. Upon our evaluation, the patient was noted to have a series of lesions on the left anterior chest wall, mid-clavicular region overlying his pacemaker pocket. Three traumatic bruises were noted ( Figure 1 ). Two discrete sites of superficial trauma were located just beneath the original, well-healed incision, with the lateral site being somewhat larger. There was also one additional site of trauma inferior to the above which appeared less healed. The remainder of the skin in the region was intact, with mild erythema in a triangular shape noted with the original device incision serving as the apex. No open skin was noted at this time, nor was there exposure of any device components.

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Figure 1: Admission.

Multiple attempts at device interrogation proved unsuccessful, thus the decision was made to replace the device. Due to the patient's tenuous, agitated, and at times aggressive psychiatric state with residual suicidal ideation, it was decided that the procedure should be performed under general anesthesia to better protect the patient's airway. Broad-spectrum intravenous antibiotics were administered as blood cultures from the transferring facility were still pending. We obtained a complete blood count, which demonstrated normal white blood cells, coagulation, and repeat blood cultures. Due to the patient's unstable mental status and agitation compounded with his unstable hemodynamic condition, it was decided a temporary pacemaker would not be tolerated. After discussions with the patient's power of attorney, it was decided to replace the generator and or leads as needed.

After local anesthetic infiltration, an incision was made over the previous scar. No purulent discharge was noted in the pocket and additional wound cultures were obtained. The device was retrieved and upon visual inspection, a total of six indentations of a well-circumscribed nature were noted on the anterior aspect of the can ( Figure 2 ). Two of the six indentations penetrated the titanium case and one caused a concave protrusion on the deep posterior aspect of the can ( Figure 3 ), almost penetrating both the front and back of the titanium casing. The pulse generator was then disconnected from the can.

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Figure 2: Front view of can post explant.


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Figure 3: Rear view of can post explant. Arrows indicate penetration of titanium. Arrow indicates protrusion from impact. Pulse generator case through pulse generator.

Upon inspection of the leads, no apparent damage was visually detected. Checking lead integrity through the pacing system analyzer revealed an electrically compromised right ventricular lead. The atrial lead was intact and provided adequate pacing, sensing, and impedance. Subsequently the right ventricular lead was extracted and a new 1888T lead (St Jude Medical, Sylmar, CA) was placed into the right ventricular outflow tract. To discourage future attempts to damage the device, the new pulse generator was placed in a deep sub-pectoral pocket and the incision was closed.

The manufacturer's analysis reported puncture holes noted on the device casing. The superior penetration was noted on top of the battery ( Figure 4 ). Excessive body fluids were noted inside of the device casing and on the circuitry ( Figure 5 ). Electrical tests were performed and indicated that the pacemaker had no output and no telemetry was possible with a 500-ohm load at 42°C. Additional attempts to measure output using an oscilloscope also demonstrated no output. It was felt these failures were due to excessive body fluids that caused shorting to the device circuitry. The extracted lead suffered a breach of the insulation.

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Figure 4: X-ray of can post implant.


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Figure 5: Opened can with body fluids. Arrows indicate punctures on top of inside of titanium case and noted on the battery hybrid.

Discussion

Blunt trauma as a mode of pacemaker failure has been previously reported in the literature 1–3 and is frequently associated with trauma to the leads at or near the location of the pocket. The mode of trauma ranges from deceleration injuries 2 to blunt trauma with a baseball bat. 3 Most common in clinical practice, external traumatic insult to implanted devices is of insufficient force to cause any permanent damage to device function.

Self-inflicted causes of device failure are somewhat rare in occurrence, with the exclusion of twiddler's syndrome first described by Bayliss and colleagues. 4–6 The body of published literature on self-inflicted pacemaker trauma is very limited. 7–9 Given the increasing number of patients receiving implantable cardiac devices, the impact of receiving an implantable device on a patient with an already diagnosed psychiatric condition should be carefully evaluated at the time of implant. The incidence of schizophrenia has been reported to range from 7.7 to 43 per 100,000. 10–12 However, diagnosis of freedom from psychiatric disorders at the time of implant does not preclude patients from this type of event reoccurring. Nonetheless, knowing the diagnosis or risk factors of the disease earlier may help with placement of these devices, for example deep pectoral placement as an alternative. Some studies have shown late-onset paranoid ideation as first onset estimated to be between 4% and 6%; however, most are concomitantly diagnosed with dementia. 13,14 Patients with a first diagnosis at 40 years have been estimated at 23.5% 15 with a 1-year prevalence rate of 0.6% until 64 years of age. 16 After 60 years of age, first admission schizophrenia-like psychosis increases by 11% with each 5-year increase in age. 17 These factors suggest that during the subsequent follow-up years, psychological screening should be repeated annually along with device interrogation to help us intervene and mitigate these events whenever possible.

Patients with implantable devices face myriad psychological considerations which should be continually monitored. These include the presence of a foreign object implanted in the body, concerns over lead or device malfunction, recalls, and battery depletion as well as a continued reminder of their disease state. Although these fears may only affect a small subset of our patient population, care identifying these patients early is paramount. The psychological impact of implantable devices has been underscored over the years with some emphasis on inappropriate high-voltage therapy delivered through implantable defibrillators. 18–20 This report underscores the importance of continued psychological evaluation of all device patients including low-voltage implantable devices.

References

  1. Kronzon I, Mehta S. Broken pacemaker wire in multiple trauma: A case report. J Trauma 1974; 14:82–84.
  2. Grieco JG, Scanlon PJ, Pifarré R. Pacing lead fracture after a deceleration injury. Ann Thorac Surg 1989; 47:453–454.
  3. Brown K, Carter W, Lombardi G. Blunt trauma-induced pacemaker failure. Ann Emerg Med 1991; 20:905–907.
  4. Bayliss C, Beanlands D, Baird R. The pacemaker-twiddler's syndrome: a new complication of implantable transvenous pacemakers. Can Med Assoc 1968; 99:371–373.
  5. Stanford W, Coylel FL, Dooley BN, Hood RH. Transvenous pacemaker failure: Migration of catheter lead by patient manipulation. Ann Thorac Surg 1968; 5:162.
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  13. Christenson R, Blazer D. Epidemiology of persecutory ideation in an elderly population in the community. Am J Psychiatry 1984; 141:1088–1089.
  14. Forsell Y, Henderson AS. Epidemiology of paranoid symptoms in an elderly population. Br J Psychiatry 1998; 172:429–432.
  15. Harris MJ, Jeste DV. Late onset schizophrenia: An overview. Schizophrenia Bull 1988; 14:39–45.
  16. Keith SJ, Regier DA, Rae DS. Schizophrenic disorders in Psychiatric Disorders in America. Robins LN, Regier DA, eds. New York, Free Press; 1991:33–52.
  17. Van Os J, Howard R, Takei N, Murray RM. Increasing age is a risk factor for psychosis in the elderly. Soc. Psychiatry Psychiatr Epidemiol 1995; 30:161–164.
  18. Luderitz B, Jung W, Deister A. Patient acceptance of the implantable cardioverter defibrillator in ventricular tachyarrhythmias. Pacing Clin Electrophysiol 1993; 16:1815–1821.
  19. Schron EB, Exner DV, Yao Q. Improving quality of life after cardiogenic shock: do more revascularization. Circulation 2002; 105:589–594.
  20. Sweeney MO, Wathen MS, Volosin K. Appropriate and Inappropriate ventricular therapies, quality of life, and mortality among primary and secondary prevention implantable cardioverter defibrillator patients. Circulation 2005; 111:2898–2905.

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