The Role of Plastic Surgery in Management of Implantable Cardiac Devices
Sara Neimanis, MD, Serena Day, MD, Howard N. Langstein, MD, Clinton S. Morrison, MD.
University of Rochester, Rochester, NY, USA.
BACKGROUND: Approximately 300,000 patients per year require implantation of cardiac pacemaker (PPM) and defibrillator (ICD) devices. Cardiac electrophysiologists usually place the devices in subcutaneous pockets to avoid dissection of deeper tissues. However, subcutaneous device insertion in high-risk patients can lead to device erosion, exposure, infection, and poor cosmetic outcomes. These complications can be morbid in patients who are dependent on these devices. In these cases, submuscular implantation of cardiac devices may be preferred either for prevention of complications or salvage in those who have had complications. Plastic surgery consultation can aid in determining the optimal placement of these devices as plastic surgeons have expertise in the anatomy and dissection of the chest wall. METHODS: This is a descriptive study of consecutive cases of plastic surgery involvement in implantable cardiac device insertion, removal, repair, reposition, revision, or upgrade at our institution from 2010-2018. These cases were reviewed for patient demographics, reason for plastic surgery involvement, type of device, and anatomic location of device. The goal was to identify which patients benefit from plastic surgery consultation. RESULTS: Plastic surgery was consulted 89 times for assistance with implantable cardiac devices during our study period. Of these, 71 consults required operative intervention in 62 individual patients. ICDs accounted for 45 consults and PPMs for the other 26. There were 28 male patients and 34 female. Average age was 56.8 (range 10.6 - 91.6 years) and average BMI was 26.5 (range 15.5 - 45.2). Patients had undergone an average of 2.2 electrophysiology procedures prior to plastic surgery consultation. The most common reasons for plastic surgery involvement were erosion/impending exposure and device issue/scheduled generator changes. Other reasons for consultation were: device exposure/extrusion, wounds after device removal, cosmetic purposes for initial device placement, malposition, pain, infection, hematoma, and unsatisfactory scars. Forty-three pocket revisions were performed, most commonly changing from a subcutaneous to submuscular pocket. Eight operations were performed for initial device placement, mostly in submuscular pockets (6 patients), and were generally performed in younger (average age 29.3) and lower BMI (average 23.2) patients. CONCLUSIONS: Plastic surgeons can play an important role in the management of implantable cardiac devices ranging from assistance with device complications to prevention of complications by identifying patients who may benefit from PRS consults prior to initial placement. It is important to spread awareness of this option to optimize care for these patients.
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