![]() ![]() In another study of 133 patients, 2 patients (1.5%) had device erosion and 3 patients (2.3%) had site infections.In a study of 154 patients, only 1 patient (0.6%) had device erosion through the skin, and none had site infections.While complications of implantable loop recorders are rare, devices can be subject to migration and erosion through the skin into the cardiac or pleural space, incision site infection, and device malfunction. 1,2 Unlike the other devices, ILRs are not in any way connected to the heart or vasculature and therefore pose minimal risk of complications – unless they migrate. As opposed to the other devices, ILRs are minimally invasive – generally, a shallow incision is made at the left parasternal area at the level of the 4th–5th intercostals, the device is inserted subcutaneously, and the incision is closed with sutures, sterile strips, glue, or a combination. Of these, implantable cardiac defibrillators, pacemakers, and biventricular devices all share a common insertion and placement site with a subcutaneous battery on the left side of the chest around the third intercostal space, wires traveling from the battery through the left subclavian vein, through the superior vena cava, and terminating inside the right ventricle (or the coronary sinus vein, in the case of the biventricular device). The most commonly encountered devices are implantable cardiac defibrillators, pacemakers, biventricular devices, and implantable loop recorders. When a patient presents to the emergency department with an implanted cardiac device extruding from the skin, the first question an emergency physician must ask after ensuring that the patient is hemodynamically stable is: what kind of device is this? As the patient may not always know the answer, it is useful to generally be aware of the different types and placement locations of cardiac devices. The 1.5 cm wound was left open to heal, and the patient was discharged home on an oral antibiotic for 7 days without any further complications. The cardiac electrophysiologist team came to assess the patient and extracted the ILR. Upon further investigation, he was able to tell us that the device was an implantable loop recorder. There was no visible hematoma, tracking gas, or pneumothorax evident on imaging. The ILR was seen to the left of the sternum between the fourth and fifth ribs. Chest x-ray showed clear lung fields and a normal-sized heart. Additionally, his lung exam demonstrated bilateral, clear breath sounds.ĮKG showed normal sinus rhythm. His cardiac exam demonstrated a regular rate and rhythm, without any evidence of murmurs, rubs, or gallops. There was mild erythema and tenderness to palpation but no purulent discharge. Physical exam showed a small cardiac device protruding about 2 cm from the patient’s skin on his anterior chest wall. The patient was afebrile and hemodynamically stable upon triage. He denied any recent trauma to the chest, fevers, chills, erythema, purulent discharge, palpitations, shortness of breath, or diaphoresis. Other than mild pain directly at the site of open skin, he denied any chest pain, palpitations, or dizziness. He reports he had woken up this morning and noticed the device sticking halfway out of his chest. However, rare complications of infection or migration of the device can occur, and when these patients come to the emergency department (ED), the emergency physician must be able to discern which cardiac device the patient has implanted and just how life-threatening the presentation might be.Ī 63-year-old male presented to the ED with a chief complaint of “my cardiac device is coming out of my skin.” The device had been implanted two weeks prior to monitor his palpitations. Unlike the more invasive implantable cardiac defibrillator, pacemaker, or biventricular device, insertion of ILRs is less invasive and is often placed in an outpatient setting under local anesthesia. Implantable loop recorders (ILRs), on the other hand, are inserted subcutaneously and are able to continuously record cardiac activity for up to 3 years. From unexplained syncopal events to undiagnosed palpitations, there are many cardiac conditions where patients benefit from closer monitoring.Įvent monitors and Holter monitors have been traditionally used to observe cardiac rhythm in patients, but these devices are externally worn and cumbersome, limiting their use. ![]()
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