A Case of Delayed Non-infective Cystic Swelling at the Pacemaker Pocket Site

With the expanding indications for device implantation, the number of cardiac implantable electrophysiological devices (CIED) being implanted has increased drastically. In a patient presenting with swelling at the pacemaker pocket site several years after the implantation, an infective collection due to device seeding by blood-borne microorganisms is the first diagnosis that is commonly considered. Once the diagnosis of CIED infection is made, complete removal of all the hardware is usually performed. We are describing an unusual case of a 70-year-old male with a permanent pacemaker implanted 8 years ago, who came with insidiously growing swelling at the pacemaker pocket site. He was afebrile. On examination, the swelling was soft and mobile and had no signs of inflammation. Blood cultures after 3 days of incubation did not show any growth. Ultrasound examination revealed a cystic swelling with thick septations. CT showed features suggestive of a seroma measuring 6.7 x 9.4 x 11 cm. Antibiotics were given empirically. A total of 100ml of serosanguinous fluid was drained and the pocket wall was excised. Pulse Generator (PG) was placed back into the pocket and the leads were reconnected. Culture and sensitivity testing of the drained fluid and excised tissue did not show any growth and microscopy revealed no abnormal cells. The patient was followed up on a regular basis for six months. There was no recurrence of swelling at the pacemaker site. Even though an infective abscess is the commonest cause of pacemaker pocket swelling, a non-infective swelling, however rare, must be considered as a non-infective swelling does not require complete removal of the hardware.