Atrial Flutter and Antitachycardia Pacemaker

The patient is a 75-year-old white gentleman with a history of symptomatic paroxysmal atrial fibrillation (AF) and left atrial flutter (AT), who underwent 2 prior radiofrequency ablations in 2008. They included pulmonary venous antral isolation, left atrial roof line, lateral mitral annular isthmus line, and a right atrial cavo-tricuspid isthmus line.

Figure 1: Pain and redness over pacemaker pocket.
Pain and redness over pacemaker pocket.
He developed recurrent, drug-refractory left atrial tachycardia and presented for a third EP study and RF ablation. In light of a third attempt at controlling his atrial tachyarrhythmia, it was decided to implant a pacemaker with atrial antitachycardia pacing (ATP) capabilities if atrial tachycardia could not be eliminated.

Past Medical History

Paroxysmal symptomatic atrial tachyarrhythmias as described above, one vessel coronary artery disease, dyslipidemia, gout, and thyroid disorder.

EP Procedures

On the day of the procedure, the patient was in atrial tachycardia at a cycle length of 360 ms. This terminated during catheter placement and could not be reproduced. Gaps in the pulmonary veins, LA roof line, and mitral isthmus line were identified and treated with RF energy application empirically. A dual chamber pacer (Medtronic EnRhythm DR) was implanted based on prior discussion. The pacemaker was programmed in the MVP (managed ventricular pacing) mode, with active atrial ATP operation.

Subsequent Course

A week after, the patient presented to the arrhythmia clinic with a two-day history of low-grade fever, pain and redness over the pacemaker pocket. Interrogation of the device showed normal function without recurrent AT.

Physical Exam

VS HR 86, BP 123/64, RR 16, SaO2 98% on 2 L, and temperature 101.4° F
Neck 4 cm JVP
Lungs Clear bilaterally
Left pectoral area Significant erythema with a yellow exudate, skin exfoliation, and patches of bluish discoloration
CV Regular S1S2; no appreciated murmur, gallop or rub
Abdomen Unremarkable
Extremities Warm, no pitting edema; symmetrical pulses
Neurologic Exam Normal

Laboratory Values

Hgb: 12.6 (12.9 – 16.9 g/dl)
Platelets: 145 x103 (150 – 350 x103/ul)
WBC: 15.1 x103 (4.5 – 11 x103/ul)
Serum Creatinine: 1.2 (0.6 – 1.5 mg/dl)

Culture and gram stain were acquired from the exudate. The patient was hospitalized and was started on antimicrobial therapy (Vancomycin and Ceftriaxone). The next day, the pacemaker system was explanted and the pocket debrided. A drain was placed. Blood cultures were obtained during fever spikes.

Despite this therapeutic approach, the wound continued to heal extremely poorly and became increasingly erythematous and excoriated (see figure). WBC count rose to 25,000, and temperatures as high as 103° F were recorded. All cultures remained negative and organisms were not seen on gram stain staining.

The best therapeutic/diagnostic option for the patient at this point would be:

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