Recognition and correction of subcuticular malposition of pacemaker pulse generators

Implantation of a cardiac pacemaker should be in the tissue plane deep to t he subcutaneous tissue (i.e., between the fatty layer and the pectoralis fa scia of the chest wall). Five patients with pacemaker implants between the cutis and the subcutaneous fat presented months later with chronic, unremit ting, and often excruciating pain. The pulse generator in each case seemed excessively superficial and displaced, appeared too large for its known siz e, and was seemingly fixed to the overlying skin with exquisite sensitivity to light touch by a garment or palpation. Each had multiple consultations and treatments for pain, all without effect other than the temporary relief of local anesthesia. In three patients with obvious large subcutaneous fat ty layers, the pulse generator was markedly superficial. Wound cultures wer e sterile in each case. Correction consisted of operative repositioning of the pulse generator into the readily developed subcutaneous tissue plane. I n each patient, total and permanent relief of pain was achieved. Subcuticul ar positioning of permanent pacemaker pulse generators causes chronic pain that is readily relieved by operative repositioning of the pulse generator in the proper tissue plane.