Images in Emergency Medicine: Pacemaker Extrusion Causing Chest Pain

A 55-year-old Hispanic male had a pacemaker placed in Mexico approximately one year prior to presenting to the Emergency Department. He noticed minor discomfort in his left chest one month earlier but did not see a physician. The discomfort steadily increased and he saw a small piece of metal poking through the skin. He assumed it was a staple or something minor related to the surgery; however, it gradually increased in size over the next few weeks until he realized it was the pacemaker itself eroding though his chest wall. A cardiology consultation was called, and an EKG showed that the pacemaker was still functioning normally. He was admitted with a plan for operative repair. Pacemaker erosion or extrusion has been reported in 0.9% of patients receiving the device.1 The two main causes are infection and pressure necrosis.1,2,3 Infection has been shown to be reduced by antibiotic treatment during the peri-placement period, and pressure necrosis appears to be influenced largely by the size of the device, complexity of the connections and technical skill with which the pocket is created.1,2 After extrusion, the pacemaker should be considered contaminated and removed.