Management of pacemaker lead decubitus in an adult with repaired tetralogy of Fallot: A case report.

introduction and importanceAdults with congenital heart disease (ACHD) often rely on long-term cardiac pacemaker therapy, which can lead to late complications. This case highlights the management of pacemaker lead decubitus in a patient with repaired Tetralogy of Fallot (TOF). CASE PRESENTATION: We report the case of a 71-year-old woman with advanced skin erosion over her pacemaker site. She underwent surgical repair of Tetralogy of Fallot in 1967. In 1977, she was diagnosed with complete heart block and received an abdominal epicardial VVI pacemaker. In 1996, skin perforation occurred at the generator site, leading to its removal and implantation of a transvenous VVI pacemaker from the right infraclavicular region. Due to pacemaker syndrome, an upgrade to a DDD system was performed in 2004. Generator replacements followed in 2012 and 2023. At the time of admission, the patient was clinically stable with no signs of systemic infection. Laboratory tests and inflammatory markers were normal. Transthoracic echocardiography revealed typical postoperative TOF anatomy, preserved left ventricular function, and mild mitral regurgitation. Transesophageal echocardiography showed no vegetations on the leads or valves. CT angiography confirmed patent venous access. With cardiothoracic and vascular surgical backup, we performed percutaneous extraction of the DDD pacemaker system without complications. As the patient was pacemaker-dependent, a temporary active fixation lead was placed via the left subclavian vein and connected to an external generator. After five days of negative blood cultures, we implanted a leadless VDD-pacemaker. The patient recovered uneventfully and was discharged the following day in good condition. CLINICAL DISCUSSION: In cases of device erosion or lead decubitus, complete removal of all pacemaker hardware is mandatory to prevent or treat potential infections. For patients who are pacemaker dependent, temporary pacing using an active fixation lead connected to an external generator is a practical bridge while diagnostic evaluation and definitive planning are underway. In this case, implantation of a leadless pacemaker with AV-synchrony offered a safe and effective long-term solution.

conclusionOur report underscores the importance of individualized pacing strategies in ACHD patients. Leadless pacemakers offer a promising alternative for patients requiring long-term pacing to eliminate the traditional complications of transvenous devices.