Wandering Pacemaker: A Case Report

Wandering Pacemaker: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Wandering Pacemaker: A Case Report Plicy Perez-Kersey, Roberto G. Gallotti, Lester C. Permut, Christina L. Greene This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4577967/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Pacemaker implantation in children is nuanced. While indications for permanent pacing are similar to those in adults, the logistics of implanting large generators in small infants and children introduces many potential complications, perhaps most insidious migration. In small children, pacemaker leads are placed on the epicardium via sternotomy and the generator is placed anterior or posterior to the rectus abdominis sheath. This precarious position is prone to erosion. Case Presentation Our patient is an 8-year-old female with an underlying glycosylation disorder with multi-organ involvement and global developmental delay. She underwent permanent pacemaker placement at 2 years of age due to prolonged sinus pauses of unclear etiology. She presented to care several times for non-specific illness symptoms, with the pacemaker ultimately being found to have migrated into the gastrointestinal tract. The device was safely extracted via the rectum by general surgery. Conclusions We present a case of pacemaker migration into the gastrointestinal tract, review the literature on this infrequent but significant complication, and provide recommendations to aid in the prompt recognition of this predicament. This case highlights that routine assessment of a pacemaker’s position and function is critical to ensuring patient safety. Pacemaker complications pacemaker migration pediatric pacemakers Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Indications for pacemaker implantation are similar in adults and children. However, the implantation procedure, postoperative management, and associated risks are quite different. The logistics of implanting large generators in small infants and children are complex. Given the limited real estate of the great vessels and heart, pacemaker leads are often placed on the epicardium via sternotomy while the generators are relegated to the upper abdomen, placed between the posterior rectus sheath and pre-peritoneal fascia. This precarious position is prone to erosion into the intra-abdominal cavity and organs. Implantation in pediatric patients is often further complicated by abnormal cardiac anatomy and aberrant connections like Fontan conduits. Multiple reoperations and scarring impact lead capture and increase pacing thresholds. Additionally, most children will need multiple generator changes before adulthood, and pacing leads may stretch and fracture with somatic growth. The multitude of ever-changing variables for children growing with permanent pacemakers makes them prone to complications not just post-procedurally but throughout their childhood. To highlight these important considerations, we present a case of pacemaker migration in a young girl with severe global developmental delay secondary to a metabolic disorder. Case Presentation Our patient is an 8-year-old female with a complex medical history including an underlying glycosylation disorder associated with profound global developmental delay, hypotonia, cortical blindness, hearing loss requiring hearing aids, epilepsy, immunodeficiency, gastrojejunostomy tube dependence, and chronic respiratory failure requiring non-invasive positive pressure. At 7 months of age, she was diagnosed with frequent prolonged sinus pauses of unclear etiology which were initially medically managed. At 2 years of age, she underwent permanent pacemaker implantation via a sub-xiphoid approach as these episodes did not improve with medical therapies. The pacemaker was placed in the pre-peritoneal space in proximity to a previously placed gastrostomy tube (Fig. 1 ). Subsequent device interrogations over several years showed that back-up pacing for heart rates less than 40 beats per minute was required < 0.1% of the time. Given clinical and device stability, she was seen by her electrophysiologist on an annual basis with remote device interrogations every 3 months. By age 7, several remote device interrogations demonstrated 0% ventricular pacing. At an outpatient visit one year prior to the case presentation, there were technical difficulties establishing a connection with the device. An abdominal X-ray was performed, which reported: “Overall similar position of pacemaker with epicardial leads in place. No evidence of fractures.” Using a new monitor, connection with the pacemaker was re-established, with two successful interrogations thereafter. Several months later, the patient presented to the emergency department (ED) for evaluation of an urticarial rash. Due to fever to 38.7°C and tachycardia to 154 beats per minute, an infectious work-up was performed. Urinalysis was concerning for recurrent urinary tract infection, so she was started on antibiotics and discharged to her nursing care facility. She returned one day later with persistent rash as well as new feeding intolerance, diarrhea, and increased oxygen requirement. Her symptoms resolved without intervention and she was discharged. The next day, nurses at her care facility noted pacemaker leads protruding from her rectum during a diaper change. She returned to the ED where a 2-view abdominal X-ray showed the pacemaker overlying the rectum (Fig. 2 ). Cardiology and general surgery were consulted. A computed tomography scan of the abdomen was performed which confirmed the pacemaker and leads were in the rectum, without associated pneumoperitoneum. The patient was taken to the operating room where the device was successfully removed from the rectum by general surgery. A small mucosal tear was seen during removal, and anal sphincter tone was noted to be intact. She was discharged the following day and was doing well at a follow-up cardiology visit one week later. Discussion and Conclusions This case of pacemaker migration into the gastrointestinal tract raises multiple important considerations for the paced pediatric patient and underscores several opportunities for improvement. When assessing a child with a permanent pacemaker, it is essential to understand their cardiac diagnoses and indications for pacing. The most common indications include: 1) symptomatic sinus bradycardia (following age-dependent norms for heart rates), 2) advanced second- or third-degree atrioventricular block, and 3) prevention or termination of tachyarrhythmias. Based on the most recent consensus statement released in 2021 by the Pediatric and Congenital Electrophysiology Society (PACES), there is no minimum heart rate or maximum duration of asystole for which permanent pacing is absolutely recommended. 1 In this case, the etiology of our patient’s sinus node dysfunction remained unclear, and the decision to implant a permanent pacemaker was based on the rarity of her metabolic disorder and lack of information on potential cardiac manifestations. The PACES committee supports a shared-decision making model, particularly in complex cases such as the present one. 1 While indications for pacemaker placement may be met, it is imperative to continually reassess the need for pacing and to seriously consider device removal when the patient consistently demonstrates normal electrical activity and conduction, as was established in this case. In addition, the evaluating provider should ensure that the pacemaker is located in the expected position and that it functions appropriately. Based on consensus expert opinion, the PACES committee issued a level IIa recommendation for a two-view chest X-ray at the first post-implant in-person evaluation and every 1–3 years thereafter based on patient-specific considerations. 1 Imaging should be used to critically assess the integrity and location of the leads and generator, making sure to explicitly state the indication for the study so the interpreting radiologist understands the clinical context. We also propose obtaining imaging when there is a specific clinical concern for device malfunction or malposition. While our patient had multiple films performed over the years, only two were specifically dedicated to assessing the position of the pacemaker. Upon further review of her radiographs, it was noted that the pacemaker gradually migrated from its original position in the midline epigastric region over the past year, highlighting the importance of a thorough review of imaging studies by all members of the medical team (Fig. 3 ). The technical challenges associated with pacemaker implantation in pediatric patients contribute to complications such as device migration and infection. 2 For infants and small children, epicardial systems are required; the generator is implanted within the rectus abdominis sheath and the leads extend onto the epicardial surface. Our patient had an existing gastrojejunostomy tube, limiting the space available in the abdomen for the generator. Close proximity of these devices can increase the risk of infection of the pacemaker system, particularly in the immediate post-operative period. Additionally, the strength of the abdominal wall can be compromised by multiple abdominal surgeries, thereby increasing the risk of pacemaker migration. With this in mind, providers should include an assessment of the pacemaker pocket in the physical exam. Pacemaker malfunction or infection can have varied and vague presentations, including: malaise, fatigue, dizziness, syncope, chest pain, palpitations, difficulty breathing, gastrointestinal symptoms such as abdominal pain and vomiting, fever, and rash. Some patients may also complain of extracardiac sensations due to electrical stimulation of other tissues. Thus, it is necessary to consider the presence of a pacemaker when formulating a comprehensive differential diagnosis for these patients. Figure 4 summarizes our recommended approach for a thorough assessment of infants and children with permanent pacemakers presenting to care in any setting. A literature review spanning the last 40 years identified several case reports of device migration in pediatric and adult patients. In one case, a 6-year-old boy with a permanent pacemaker placed within the posterior rectus sheath for management of complete heart block presented with mild intermittent, nonspecific lower abdominal pain and fever. 3 His abdominal exam was benign, but a radiograph and ultrasound showed the device located in the pelvic cavity without evidence of visceral injury; the device was removed laparoscopically. A 2-year-old girl with the same diagnosis suffered from intermittent abdominal pain and presented to care once her family noticed prolapse of the device via the rectum. 4 Her pacemaker pocket was infected and a temporary colostomy was required. A third case summarized the experience of a middle-aged man with second-degree heart block whose pacemaker lead perforated the right ventricular free wall, prompting urgent cardiothoracic surgery for lead replacement and right ventricular repair. 5 This patient presented with chest pain and his electrocardiogram showed loss of pacing. These cases stress that pacemakers cannot only migrate, but can also perforate or erode into any body tissue, including the gastrointestinal system and heart. As such, routine monitoring of the location and function of these devices is critical. Lastly, one must consider the child’s stage of development when weighing the risks and benefits of pacemaker implantation and when addressing an acute clinical concern. Our patient’s medical complexity and severe global developmental delay contributed both to the decision to implant the pacemaker and to the delay in identifying the device’s migration. This case emphasizes that non-verbal infants and children who cannot directly communicate their symptoms are particularly vulnerable to important complications being unintentionally missed. Thus, the provider’s index of suspicion for a pacemaker-related issue must be high. Abbreviations ED Emergency Department PACES Pediatric and Congenital Electrophysiology Society Declarations Ethics approval and consent to participate: Not applicable. Consent for publication: Signed consent for publication was obtained from the patient’s parent. Availability of data and materials: Not applicable. Competing interests: The authors declare that they have no competing interests. Funding: Not applicable. Authors' contributions PPK, RG, LP and CG conceptualized and designed the study, collected data, and reviewed and revised the manuscript. PPK and CG drafted the initial manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. Acknowledgements: Not applicable. References Members WC, Silka MJ, Shah MJ, et al. 2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices in Pediatric Patients: Executive Summary. Ann Pediatr Cardiol. 2022;15(3):323–46. 10.4103/0974-2069.361245 . Cohen MI, Bush DM, Gaynor JW, Vetter VL, Tanel RE, Rhodes LA. Pediatric pacemaker infections: twenty years of experience. J Thorac Cardiovasc Surg. 2002;124(4):821–7. 10.1067/mtc.2002.123643 . Alawami MH, Alzayer EA, Alqattan HM, et al. Laparoscopic extraction of a migrated pacemaker in a 6-year-old child: A case report. JTCVS Tech. 2022;16:227–30. 10.1016/j.xjtc.2022.09.019 . Koch AM, Singer H. Unusual pacemaker migration. Eur Heart J. 2005;26(19):1941. 10.1093/eurheartj/ehi488 . Cañizares-Otero MC, Danckers M. Pacemaker Lead Migration and Ventricular Perforation in a Patient Presenting with Chest Pain. Clin Pract Cases Emerg Med. 2021;5(4):479–81. 10.5811/cpcem.2021.7.52689 . 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4577967","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":320591472,"identity":"4ec7e51f-4121-45a2-ae52-1f823112d593","order_by":0,"name":"Plicy Perez-Kersey","email":"data:image/png;base64,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","orcid":"","institution":"University of Washington","correspondingAuthor":true,"prefix":"","firstName":"Plicy","middleName":"","lastName":"Perez-Kersey","suffix":""},{"id":320591473,"identity":"01379961-a640-40f7-bb09-bc5c375ec38a","order_by":1,"name":"Roberto G. 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However, the implantation procedure, postoperative management, and associated risks are quite different. The logistics of implanting large generators in small infants and children are complex. Given the limited real estate of the great vessels and heart, pacemaker leads are often placed on the epicardium via sternotomy while the generators are relegated to the upper abdomen, placed between the posterior rectus sheath and pre-peritoneal fascia. This precarious position is prone to erosion into the intra-abdominal cavity and organs. Implantation in pediatric patients is often further complicated by abnormal cardiac anatomy and aberrant connections like Fontan conduits. Multiple reoperations and scarring impact lead capture and increase pacing thresholds. Additionally, most children will need multiple generator changes before adulthood, and pacing leads may stretch and fracture with somatic growth.\u003c/p\u003e \u003cp\u003eThe multitude of ever-changing variables for children growing with permanent pacemakers makes them prone to complications not just post-procedurally but throughout their childhood. To highlight these important considerations, we present a case of pacemaker migration in a young girl with severe global developmental delay secondary to a metabolic disorder.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eOur patient is an 8-year-old female with a complex medical history including an underlying glycosylation disorder associated with profound global developmental delay, hypotonia, cortical blindness, hearing loss requiring hearing aids, epilepsy, immunodeficiency, gastrojejunostomy tube dependence, and chronic respiratory failure requiring non-invasive positive pressure. At 7 months of age, she was diagnosed with frequent prolonged sinus pauses of unclear etiology which were initially medically managed. At 2 years of age, she underwent permanent pacemaker implantation via a sub-xiphoid approach as these episodes did not improve with medical therapies. The pacemaker was placed in the pre-peritoneal space in proximity to a previously placed gastrostomy tube (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSubsequent device interrogations over several years showed that back-up pacing for heart rates less than 40 beats per minute was required\u0026thinsp;\u0026lt;\u0026thinsp;0.1% of the time. Given clinical and device stability, she was seen by her electrophysiologist on an annual basis with remote device interrogations every 3 months. By age 7, several remote device interrogations demonstrated 0% ventricular pacing. At an outpatient visit one year prior to the case presentation, there were technical difficulties establishing a connection with the device. An abdominal X-ray was performed, which reported: \u0026ldquo;Overall similar position of pacemaker with epicardial leads in place. No evidence of fractures.\u0026rdquo; Using a new monitor, connection with the pacemaker was re-established, with two successful interrogations thereafter.\u003c/p\u003e \u003cp\u003eSeveral months later, the patient presented to the emergency department (ED) for evaluation of an urticarial rash. Due to fever to 38.7\u0026deg;C and tachycardia to 154 beats per minute, an infectious work-up was performed. Urinalysis was concerning for recurrent urinary tract infection, so she was started on antibiotics and discharged to her nursing care facility. She returned one day later with persistent rash as well as new feeding intolerance, diarrhea, and increased oxygen requirement. Her symptoms resolved without intervention and she was discharged. The next day, nurses at her care facility noted pacemaker leads protruding from her rectum during a diaper change. She returned to the ED where a 2-view abdominal X-ray showed the pacemaker overlying the rectum (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Cardiology and general surgery were consulted. A computed tomography scan of the abdomen was performed which confirmed the pacemaker and leads were in the rectum, without associated pneumoperitoneum. The patient was taken to the operating room where the device was successfully removed from the rectum by general surgery. A small mucosal tear was seen during removal, and anal sphincter tone was noted to be intact. She was discharged the following day and was doing well at a follow-up cardiology visit one week later.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion and Conclusions","content":"\u003cp\u003eThis case of pacemaker migration into the gastrointestinal tract raises multiple important considerations for the paced pediatric patient and underscores several opportunities for improvement.\u003c/p\u003e \u003cp\u003eWhen assessing a child with a permanent pacemaker, it is essential to understand their cardiac diagnoses and indications for pacing. The most common indications include: 1) symptomatic sinus bradycardia (following age-dependent norms for heart rates), 2) advanced second- or third-degree atrioventricular block, and 3) prevention or termination of tachyarrhythmias. Based on the most recent consensus statement released in 2021 by the Pediatric and Congenital Electrophysiology Society (PACES), there is no minimum heart rate or maximum duration of asystole for which permanent pacing is absolutely recommended.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e In this case, the etiology of our patient\u0026rsquo;s sinus node dysfunction remained unclear, and the decision to implant a permanent pacemaker was based on the rarity of her metabolic disorder and lack of information on potential cardiac manifestations. The PACES committee supports a shared-decision making model, particularly in complex cases such as the present one.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e While indications for pacemaker placement may be met, it is imperative to continually reassess the need for pacing and to seriously consider device removal when the patient consistently demonstrates normal electrical activity and conduction, as was established in this case.\u003c/p\u003e \u003cp\u003eIn addition, the evaluating provider should ensure that the pacemaker is located in the expected position and that it functions appropriately. Based on consensus expert opinion, the PACES committee issued a level IIa recommendation for a two-view chest X-ray at the first post-implant in-person evaluation and every 1\u0026ndash;3 years thereafter based on patient-specific considerations.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Imaging should be used to critically assess the integrity and location of the leads and generator, making sure to explicitly state the indication for the study so the interpreting radiologist understands the clinical context. We also propose obtaining imaging when there is a specific clinical concern for device malfunction or malposition. While our patient had multiple films performed over the years, only two were specifically dedicated to assessing the position of the pacemaker. Upon further review of her radiographs, it was noted that the pacemaker gradually migrated from its original position in the midline epigastric region over the past year, highlighting the importance of a thorough review of imaging studies by all members of the medical team (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe technical challenges associated with pacemaker implantation in pediatric patients contribute to complications such as device migration and infection.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e For infants and small children, epicardial systems are required; the generator is implanted within the rectus abdominis sheath and the leads extend onto the epicardial surface. Our patient had an existing gastrojejunostomy tube, limiting the space available in the abdomen for the generator. Close proximity of these devices can increase the risk of infection of the pacemaker system, particularly in the immediate post-operative period. Additionally, the strength of the abdominal wall can be compromised by multiple abdominal surgeries, thereby increasing the risk of pacemaker migration. With this in mind, providers should include an assessment of the pacemaker pocket in the physical exam.\u003c/p\u003e \u003cp\u003ePacemaker malfunction or infection can have varied and vague presentations, including: malaise, fatigue, dizziness, syncope, chest pain, palpitations, difficulty breathing, gastrointestinal symptoms such as abdominal pain and vomiting, fever, and rash. Some patients may also complain of extracardiac sensations due to electrical stimulation of other tissues. Thus, it is necessary to consider the presence of a pacemaker when formulating a comprehensive differential diagnosis for these patients. Figure\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e summarizes our recommended approach for a thorough assessment of infants and children with permanent pacemakers presenting to care in any setting.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eA literature review spanning the last 40 years identified several case reports of device migration in pediatric and adult patients. In one case, a 6-year-old boy with a permanent pacemaker placed within the posterior rectus sheath for management of complete heart block presented with mild intermittent, nonspecific lower abdominal pain and fever.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e His abdominal exam was benign, but a radiograph and ultrasound showed the device located in the pelvic cavity without evidence of visceral injury; the device was removed laparoscopically. A 2-year-old girl with the same diagnosis suffered from intermittent abdominal pain and presented to care once her family noticed prolapse of the device via the rectum.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Her pacemaker pocket was infected and a temporary colostomy was required. A third case summarized the experience of a middle-aged man with second-degree heart block whose pacemaker lead perforated the right ventricular free wall, prompting urgent cardiothoracic surgery for lead replacement and right ventricular repair.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e This patient presented with chest pain and his electrocardiogram showed loss of pacing. These cases stress that pacemakers cannot only migrate, but can also perforate or erode into any body tissue, including the gastrointestinal system and heart. As such, routine monitoring of the location and function of these devices is critical.\u003c/p\u003e \u003cp\u003eLastly, one must consider the child\u0026rsquo;s stage of development when weighing the risks and benefits of pacemaker implantation and when addressing an acute clinical concern. Our patient\u0026rsquo;s medical complexity and severe global developmental delay contributed both to the decision to implant the pacemaker and to the delay in identifying the device\u0026rsquo;s migration. This case emphasizes that non-verbal infants and children who cannot directly communicate their symptoms are particularly vulnerable to important complications being unintentionally missed. Thus, the provider\u0026rsquo;s index of suspicion for a pacemaker-related issue must be high.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eED\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEmergency Department\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePACES\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePediatric and Congenital Electrophysiology Society\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eConsent for publication:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSigned consent for publication was obtained from the patient\u0026rsquo;s parent.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting interests:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003ePPK, RG, LP and CG conceptualized and designed the study, collected data, and reviewed and revised the manuscript.\u003c/p\u003e\n\u003cp\u003ePPK and CG drafted the initial manuscript.\u003c/p\u003e\n\u003cp\u003eAll authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003eAcknowledgements:\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMembers WC, Silka MJ, Shah MJ, et al. 2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices in Pediatric Patients: Executive Summary. Ann Pediatr Cardiol. 2022;15(3):323\u0026ndash;46. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/0974-2069.361245\u003c/span\u003e\u003cspan address=\"10.4103/0974-2069.361245\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCohen MI, Bush DM, Gaynor JW, Vetter VL, Tanel RE, Rhodes LA. Pediatric pacemaker infections: twenty years of experience. J Thorac Cardiovasc Surg. 2002;124(4):821\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1067/mtc.2002.123643\u003c/span\u003e\u003cspan address=\"10.1067/mtc.2002.123643\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlawami MH, Alzayer EA, Alqattan HM, et al. Laparoscopic extraction of a migrated pacemaker in a 6-year-old child: A case report. JTCVS Tech. 2022;16:227\u0026ndash;30. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.xjtc.2022.09.019\u003c/span\u003e\u003cspan address=\"10.1016/j.xjtc.2022.09.019\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKoch AM, Singer H. Unusual pacemaker migration. Eur Heart J. 2005;26(19):1941. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/eurheartj/ehi488\u003c/span\u003e\u003cspan address=\"10.1093/eurheartj/ehi488\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCa\u0026ntilde;izares-Otero MC, Danckers M. Pacemaker Lead Migration and Ventricular Perforation in a Patient Presenting with Chest Pain. Clin Pract Cases Emerg Med. 2021;5(4):479\u0026ndash;81. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5811/cpcem.2021.7.52689\u003c/span\u003e\u003cspan address=\"10.5811/cpcem.2021.7.52689\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Pacemaker complications, pacemaker migration, pediatric pacemakers","lastPublishedDoi":"10.21203/rs.3.rs-4577967/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4577967/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePacemaker implantation in children is nuanced. While indications for permanent pacing are similar to those in adults, the logistics of implanting large generators in small infants and children introduces many potential complications, perhaps most insidious migration. In small children, pacemaker leads are placed on the epicardium via sternotomy and the generator is placed anterior or posterior to the rectus abdominis sheath. This precarious position is prone to erosion.\u003c/p\u003e\u003ch2\u003eCase Presentation\u003c/h2\u003e \u003cp\u003eOur patient is an 8-year-old female with an underlying glycosylation disorder with multi-organ involvement and global developmental delay. She underwent permanent pacemaker placement at 2 years of age due to prolonged sinus pauses of unclear etiology. She presented to care several times for non-specific illness symptoms, with the pacemaker ultimately being found to have migrated into the gastrointestinal tract. The device was safely extracted via the rectum by general surgery.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eWe present a case of pacemaker migration into the gastrointestinal tract, review the literature on this infrequent but significant complication, and provide recommendations to aid in the prompt recognition of this predicament. This case highlights that routine assessment of a pacemaker\u0026rsquo;s position and function is critical to ensuring patient safety.\u003c/p\u003e","manuscriptTitle":"Wandering Pacemaker: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-16 15:58:51","doi":"10.21203/rs.3.rs-4577967/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8b0ebd23-8532-4f4a-9204-687ecd1bda0c","owner":[],"postedDate":"July 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-06-12T06:09:26+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-16 15:58:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4577967","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4577967","identity":"rs-4577967","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}