Editorial
The thinning of the skin and subcutaneous tissue above the pocket of
cardiac implantable electronic devices (CIED) is an is an occasional
phenomenon, which may have many reasons. The most frequently considered
are: improper CIED implantation or re-implantation with too shallow
design of the pocket, progressive weight loss (cachexia), but it can
also be the temporary first visible stage or even first symptom of CIED
pocket infection. In the observation of Yatomi et al. risk factors for
skin thinning over the generator were: low BMI, low haemoglobin level,
heart failure, malignancy and renal dysfunction. In this study, a
retrospective analysis of clinical data from a group of 101 patients
with an average lead dwell time of 95 months revealed no cases of pocket
infections in patients with thinning of the skin over the generator.
Authors recognised thinning of the skin in 17 patients (about 17%)
which indicates, that the phenomenon is not so rare. According to our
observations, too tight skin over a too tight and shallow pocket loses
its elasticity and becomes less and less mobile, and after some time,
progressive necrotic processes lead to a lack of protection against the
penetration of bacteria. Patients with a shallow CIED pocket should be
monitored by an electrocardiologist controlling the device (and
performing follow-up). Changes in the colour of the skin towards blue or
reddening, the appearance of pain or local warming, or the loss of skin
sliding over the bed, means the probable beginning of infection, which
is an indication for transvenous lead extraction (TLE). In patients with
a very superficial generator site, without signs of infection, the
possibility of deepening the pocket (so called surgical “plastic of the
CIED pocket”) is sometimes considered. Theoretically, this type of
procedure is possible, but the extremely shallow location of the unit is
accompanied by the loop of the lead growing into the skin and the
preparation of such leads is often associated with risk of their
accidental damage as well as an increased risk of developing infectious
complications. It should be emphasized that an excessively shallow
pocket is not an indication for transvenous lead extraction. Its
consequence in the form of bedsores (limited skin necrosis) or the next
stage - purulent fistula over the pocket or loop of the lead - as an
infectious complication - is already an indication for TLE ( Figure 1,
Figure 2).