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LETTERS TO THE EDITOR

Comment on the article “Prevalence and implicated risk factors associated with the exteriorization of cardiac pacemakers…”

José Rafael Cuauhtémoc Acoltzin-Vidal^a

^aUniversidad de Colima, Colima, México

Email: cuahtemoc_acoltzin@ucol.mx

Referring to the report by Marco Arguello-Hurtado et al,¹ I would say that is interesting for the casuistry they report; for the low incidence of externalization, suggesting that their work is of high quality; and because there was no association found with the proposed risk factors, which, along with the fact that the most frequent externalization is the "delayed", suggests that the problem is unrelated to the organic conditions of the patients.

Although I do not have the proper experience to analyze correctly, I dare to comment on the externalization of permanent pulse generators of cardiac pacemakers, since I started working with them in 1970 and I have written a book on the history of pacemakers, entitled De estocadas a Stokes Adams, part of the Alforja Colimense historical collection, published by the Sociedad Colimense de Estudios Históricos, A.C.²

Since then, those huge, silicone, Chardack-brand machines with angled corners and projections placed to adjust heart rate and pulse width were rejected and poorly tolerated, since they hurt the skin by stretching it a great deal.

Modern pacemakers are designed to be much less aggressive: they have titanium housings and rounded edges.

Several possibilities emerge to explain why these are externalized: if the complication is early, the cause could be massive infection from medical neglect. These infections affect the overall condition of the patient, as they can cause fever, drainage, and leukocytosis. They are serious and require aggressive treatment. It is best to avoid them by making sure that all the rules of asepsis and antisepsis are met. The pacemaker industry prepares a special antibacterial cover for use at the time of implanting.

There may be rejection of the suture material if it is organic (catgut or silk). The recommendation is to use only plastic monofilament in both deep layers and skin.

If rejection is delayed, the reason may be the generator dropping from gravitational effect, causing stretching and thinning of the skin at the site of maximum stress. To avoid this, one must properly hang the generator using a conduit designed for that purpose, or bury it behind the fascia or the pectoral muscle. We must not ignore friction with the clothes nor the fact that there are patients who scratch it voluntarily or involuntarily, which increases the damage.

References

1. Argüello-Hurtado M, Guevara-Valdivia ME, Aranda-Ayala ZL, Hernández-Lara J. Factores asociados e implicados en la exteriorización de marcapasos definitivos, seguimiento a cinco años. Rev Med Inst Mex Seguro Soc. 2015;53 Supl 1: 104-8.
2. Acoltzin C. De estocadas a Stokes-Adams. Colima, México: Sociedad Colimense de Estudios Históricos, A. C., Colección Alforja Histórica de Colima; 2004.

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