• Users Online: 741
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 4  |  Issue : 3  |  Page : 247-249

Recurrent sternal sinuses caused by retained temporary epicardial pacing wires and different wire fixation techniques


1 Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
2 Department of Cardiac Anaesthesia, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication11-Jan-2019

Correspondence Address:
Dr. Anish Gupta
Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, 98, Om Vihar, Phase-1A, Shiv Shankar Road, Uttam Nagar, New Delhi - 110 059
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcs.jpcs_35_18

Rights and Permissions
  Abstract 


Temporary epicardial pacing wires are routinely used after open-heart surgery without any major complications, but varied complications have been described with their use though rare. They are often pulled out after recovery of the patient, usually on the 4th postoperative day, but sometimes, they are cut flush with the skin, especially if they are not coming out after the usual amount of pulling force. We describe a patient who had recurrent sternal sinuses with retained pacing wires which were missed on imaging. We emphasize on the importance of proper fixing of epicardial pacing wires during cardiac surgery, the need for their complete removal after recovery and the need of documenting the same in discharge summaries if they are cut flush and retained in situ.

Keywords: Pacing wire fixation methods, sternal sinuses, temporary epicardial pacing wires


How to cite this article:
Gupta A, Devagourou V, Choudhury M, Saurabh G. Recurrent sternal sinuses caused by retained temporary epicardial pacing wires and different wire fixation techniques. J Pract Cardiovasc Sci 2018;4:247-9

How to cite this URL:
Gupta A, Devagourou V, Choudhury M, Saurabh G. Recurrent sternal sinuses caused by retained temporary epicardial pacing wires and different wire fixation techniques. J Pract Cardiovasc Sci [serial online] 2018 [cited 2019 Aug 23];4:247-9. Available from: http://www.j-pcs.org/text.asp?2018/4/3/247/249928


  Introduction Top


Temporary epicardial pacing wires (TEPW) are usually used after open heart surgery to treat common perioperative arrhythmias and are usually removed after the recovery of the patient but at some centres they are usually cut flush with the skin before the patient is discharged. The incidence of complications associated with the use of TEPW is low and if left in situ for prolonged time can produce foreign body reaction or infection can occur leading sternal sinus formation. We present one such case where the patient developed recurrent sternal sinuses due to retained TEPW which was not known before. We have also reviewed the different methods of placing TEPW during surgery and their relative safety.


  Case Report Top


A 36-year-old male who had previously undergone aortic valve replacement outside our center presented with recurrent formation of skin sinuses on his sternal scar [Figure 1]. He had already been operated for these sinuses but developed recurrence. He was worked up for tuberculosis and malignancy, but it was only chronic inflammatory and fibrotic tissue on biopsy examination. Computed tomography (CT) sinogram was done to delineate the anatomy of sinus tracts, multiple tracts were found, and no foreign body was seen. The patient underwent sinus exploration with help from the plastic surgeons. All sinuses were cored out and the tract was going into the pericardium below the xiphisternum [Figure 2]. At that time, decision was taken to do redo lower midline sternotomy, and to our surprise, temporary epicardial pacing wires (TEPWs) were found inside which were probably cut flush with the skin during thefirst surgery. Retained pacing wires having a ring at fixation end were removed [Figure 3], sinus tracts were excised, and the defect was closed using the pectoralis major myocutaneous flap [Figure 4]. The wound healed and sutures were removed on the 10th postoperative day.
Figure 1: Sternal sinuses at scar site.

Click here to view
Figure 2: Protruding temporary epicardial pacing wire.

Click here to view
Figure 3: Retained temporary epicardial pacing wire after removal.

Click here to view
Figure 4: Final wound after reconstruction.

Click here to view



  Discussion Top


TEPWs are used frequently after open-heart surgery to combat perioperative arrhythmias such as heart block and are usually removed on the 4th postoperative day if the patient is in sinus rhythm and hemodynamically stable. There are different methods used by surgeons to fix these temporary wires [Figure 5]. Ring method is one of them in which a ring of inside metal is formed and fixed to epicardium using polypropylene suture passed through its center. In hook method, a hook is formed from the inside metal and stabilized to epicardium with a Prolene suture. Third, pacing wire can be directly taken out through the myocardium with its inbuilt needle after which the needle is cut and the end of wire is rotated with thumb forceps. Sometimes, there can be difficulty in removing these wires while pulling out, especially with the ring method. In such cases or sometimes electively as per protocol in some centers, wires are cut flush with the skin and left in situ because forceful extraction of such stuck wires can lead to laceration and tamponade, while on the contrary, retained pacing wires rarely cause problems[1] and the incidence of major complications after their removal is 0.04%.[2] However, problems are also associated with retained pacing wires, and the reported complications of retained wires include minor ones such as skin pustule or abscess formation to major ones such as erosion into the diaphragm, pulmonary artery, tricuspid valve, bronchus, or lung.[3],[4],[5],[6],[7]
Figure 5: Different pacing wire fixation methods.

Click here to view


Chung and Smith also reported two cases of foreign body reactions due to retained TEPW, but in both their cases, TEPWs were confirmed on CT scan.[8] This case highlights the complications caused by retained TEPWs which are underrated and can be very troublesome for the patient after successful surgery disturbing his quality of life. It may not be possible to completely remove pacing wires each time, but if retained, it should be mentioned in the discharge summary and the surgeon should have a high index of suspicion for patients presenting with recurrent sternal sinuses without any identifiable cause. We also highlight the importance of the method of fixation of TEPWs, as in hook method and direct method, pacing wire will come out through the tract of insertion into epicardium without cutting the fixation suture, but in ring method, the ring is not going to open up, but either the suture will break or it will cut through epicardium, in which case it can cause bleeding if the bite was deep initially. It is a hypothesis, not proven by any randomized trial, but can call for further investigation.


  Conclusion Top


TEPWs should be removed as far as possible after their job is done, and cutting flush should be avoided. It may not be possible to be able to pull them out always, so if cut flush should be mentioned in discharge summary and high index of suspicion should be kept for this foreign body in postoperative recurrent sternal sinuses. Hook method or direct method is better than ring method.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Shaikhrezai K, Khorsandi M, Patronis M, Prasad S. Is it safe to cut pacing wires flush with the skin instead of removing them? Interact Cardiovasc Thorac Surg 2012;15:1047-51.  Back to cited text no. 1
    
2.
Mishra PK, Lengyel E, Lakshmanan S, Luckraz H. Temporary epicardial pacing wire removal: Is it an innocuous procedure? Interact Cardiovasc Thorac Surg 2010;11:854-5.  Back to cited text no. 2
    
3.
Benson CC, Valente AM, Economy KE, Hoffman-Sage Y, Bevilacqua LM, Podovei M, et al. Discovery and management of diaphragmatic hernia related to abandoned epicardial pacemaker wires in a pregnant woman with {S, L, L} transposition of the great arteries. Congenit Heart Dis 2012;7:183-8.  Back to cited text no. 3
    
4.
Worth PJ, Conklin P, Prince E, Singh AK. Migration of retained right ventricular epicardial pacing wire into the pulmonary artery: A rare complication after heart surgery. J Thorac Cardiovasc Surg 2011;142:e136-8.  Back to cited text no. 4
    
5.
Sheikh M, Bruhl SR, Omer S, Schwaan T, Grubb B, Cooper C, et al. Transmyocardial voyage of a temporary epicardial lead: An unusual long-term complication. Pacing Clin Electrophysiol 2012;35:e185-6.  Back to cited text no. 5
    
6.
Sakellaridis T, Argiriou M, Panagiotakopoulos V, Charitos C. Bilateral sternobronchial fistula after coronary surgery – Are the retained epicardial pacing wires responsible? A case report. J Cardiothorac Surg 2009;4:26.  Back to cited text no. 6
    
7.
Horng GS, Ashley E, Balsam L, Reitz B, Zamanian RT. Progressive dyspnea after CABG: Complication of retained epicardial pacing wires. Ann Thorac Surg 2008;86:1352-4.  Back to cited text no. 7
    
8.
Chung DA, Smith EE. Delayed presentation of foreign body reaction secondary to retained pacing wires. Ann Thorac Surg 1998;66:550-1.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
   Abstract
  Introduction
  Case Report
  Discussion
  Conclusion
   References
   Article Figures

 Article Access Statistics
    Viewed431    
    Printed43    
    Emailed0    
    PDF Downloaded50    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]