Salvaging the Cardiac Implantable Electronic Device: Transpectoral versus Lateral Pectoral Approach

Salvaging the Cardiac Implantable Electronic Device: Transpectoral versus Lateral Pectoral Approach | 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 Research Article Salvaging the Cardiac Implantable Electronic Device: Transpectoral versus Lateral Pectoral Approach PYW Adzim, RA Mukhlis, AZ Mat Saad, MA Raffali, KM Rahaman, AR Abd Ghani, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7521607/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 Cardiac implantable electronic devices (CIEDs) are a vital therapeutic measure to keep arrhythmic patients from heart failure or death. Complications of insertions are rare but may present as implant body erosions, wire erosions, infection, and chronic subclinical infection. Whilst most centres advocate device extraction and new device implantation, salvaging the implant can bring numerous benefits. We describe our experience with patients who experienced complications, for whom their devices were salvaged and reimplanted subpectorally, achieving high success rates. We also compare the differences of the transpectoral and the lateral pectoral approaches, and discuss the challenges and pre-emptive measures taken. Cardiac Implantable Electronic Device (CIED) Pacemaker Complications Device Salvage Transpectoral Reimplantation Lateral Pectoral Approach Reimplantation Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 1 Introduction Annually, 1.2–1.4 million CIEDs are implanted globally with various indications. Standard devices with leads are still required, especially for patients who require defibrillation and physiological pacing. The complications related to the insertion of the implant itself could sometimes be catastrophic to the patients, especially involving infection of the device. Infections and lead erosions are rare, at about 2%[ 1 ]. When complications arise, most centres advocate for the removal of the implant and reinsertion of a new device to avoid recurrences.[ 2 ]. However, in certain situations, this may increase risks associated with large vessel re-puncturing. And for certain parts of the world, the astronomic costs may be too significant to bear. Subpectoral repositioning of the CIED has been known since the 1950s. However, certain risks were reported by practitioners, namely recurrence and infection.[ 3 ]. Salvaging an implant is considered high risk, due to known experiences where surgical site infections may be too high. With a deeper understanding of biofilms and the role of muscular flaps in mitigating infections, we integrate complex wound management sciences with meticulous surgical techniques to achieve high success rates in salvaging CIEDs. 2 Methods This study was conducted and reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines and adhered to the principles outlined in the Declaration of Helsinki regarding research involving human subjects. We retrospectively reviewed patient records from July 2023 to August 2025. Patients referred to the Plastic and Reconstructive Surgery Unit of Hospital Canselor Tuanku Muhriz by cardiologists or electrophysiologists for implant-related complications were assessed. Reasons for referral included wire exposure, implant body exposure, non-purulent discharge, pus discharge, and life-threatening situations of infection-related implant stimulation. A multidisciplinary approach was taken, involving the electrophysiologist, anaesthesiologist, and plastic surgeon. Key factors considered during multidisciplinary discussions included: Pros and cons of salvaging the implant for the patient, compared to extraction. Optimisation of co-morbidities. Anticipation of complications. Ongoing anticoagulative therapy. Post-operative disposition. Preoperatively, systemic antibiotics were initiated to help contain the infection locally at the peri-implant site. An assessment of the extent of inflammation and damage was made to determine the anatomy involved and whether the infection had spread through natural planes. The anatomical presence of the pectoralis major muscle and clinical judgment of its thickness were assessed subjectively by asking the patient to press their hand against their waist while palpating for the muscle bulk. No preoperative imaging was required for our patients. 2.1 Surgical Method Patients were under general anaesthesia, unless specified. The cardiologist and technician were prepared for device reassessment and interrogation to make sure the device was functioning normally prior to the procedure. Incision was designed to allow access to the implant and to excise the diseased skin and tissues. This was usually around the site of skin erosion/ inflammation. The decision of incision was based on these factors: Proximity to the exposed implant part. Proximity to the main implant body. Palpable induration/ collection. A minimal access approach was taken, limiting the incision size. This usually corresponded to the least diameter of the implant. Necrotic, scarred, or senescent skin and tissue were excised in toto. Only scalpel and cold steel surgery with minimal use of bipolar cautery was used. The wires were carefully teased off all fibrosis until about 2-3cm from the subclavian entry point. The pacemaker body was retrieved and scrubbed with a chlorhexidine-soaked gauze until all visible debris was removed. Then, the body and wires were immersed sequentially in povidone 5% (100 mL), chlorhexidine gluconate 4% (100 mL), and then, lastly, in gentamicin 80mg diluted in 100 mL of normal saline, for 5 minutes each. While awaiting the immersion time, the surgeon started on the dissection of the pectoralis major pocket. This was created either via transpectoral approach or a lateral pectoral approach, as described below: 2.2 Transpectoral Approach (see Fig. 1 ) A muscle-splitting action was done through the pectoralis major, with only blunt dissection. No muscle cutting was required. Small bleeding muscle capillaries were cauterized with bipolar cautery. Using larger retractors and finger dissection, the plane between the pectoralis major and pectoralis minor muscles was identified. An exact-size pocket was created. 2.3 Lateral Pectoral Approach (see Fig. 2 ) From the original subcutaneous pocket, the skin incision was extended to the left anterior axillary line (see Figs. 3 – 5 ). The dissection was extended in the pre-deep fascial plane to the lateral border of the pectoralis major muscle. This was around 5 cm below the axilla. Blunt dissection was then employed to access the subpectoral plane, which is the area between the pectoralis major and pectoralis minor muscles, creating a pocket of about 10 cm. Occasionally, branches of the lateral thoracic artery were encountered, and they could usually be retracted out of the way without being ligated. The pacemaker body was then transferred to the subpectoral pocket and secured with monocryl 3 − 0 sutures using a round-body needle. Entrance to the pocket was approximated with 3 − 0 monocryl sutures at the muscle level. The wires were tucked maximally in the pocket, and any extra-pectoral wires were fixed and sutured under the pectoral fascia to reduce effacement. Wound was closed in layers, usually pectoral fascia, deep dermal, and skin suture. Table 1 Patient presentation, with subpectoral approaches. WD: Wound Dehiscence, IBE: Implant Body extrusion, ILE: Implant Lead Extrusion, PD: Purulent Discharge, NPD: Non-purulent Discharge, SSI: Surgical Site Infection, ICD: Implantable Cardioverter-Defibrillator. PPM: Permanent Pacemaker, CRTD: Cardiac resynchronisation therapy with pacemaker, CRTD: Cardiac Resynchronisation Therapy with Defibrillator, LP: Lateral Pectoral, TP: Transpectoral. IHD: Ischemic heart disease, HF: Heart Failure, 3VD: three vessels disease, HPT: Hypertension, AF: Atrial Fibrillation, DCM: Dilated Cardiomyopathy, CKD: Chronic Kidney Disease, DM: Diabetes Mellitus, VD: Vessel disease, VT: Ventricular Tachycardia, VF: Ventricular fibrillation, TOF: Tetralogy of Fallot, TR: Tricuspid Regurgitation, PR: Pulmonic Artery Regurgitation, N Age/ Sex Implant type Presentation Time from Implant to revision Med background Note. Cases done under GA unless specified Surgical approach 1 78/F ICD Necrotic skin, VT storm PD 1 M IHD, HF, PCI LAD, AF, RA, Echo 41% Surgery under regional block, Postoperative vacuum dressing applied LP 2 27/M PPM ILE 7 Y CHB, PDA Change of device on the table LP 3 69/M PPM Skin thinning on PPM 1 M IHD, 3VD, Mobitz I AV block. Echo 50–55% One month later, implant migration occurred along the anterior axillary line, and the implant was revised. LP 4 73/M PPM IBE, NPD 7 W HPT, IHD, 3rd deg AV block, mild AR. Echo 67% TP 5 52/M ICD Necrotic skin. 3 W HPT/DM, RWMA, Rec VT. Echo 34% with global hypokinesia TP 6 57/M ICD IBE 2 M DCM, VT, CKD. Echo 25% TP 7 67/M PPM IBE 2 Y TOF, TR, PR, AR, residual VSD, Mechanical aVR SJM, Permanent AF with VVIR. On warfarin. Echo 55% Prolonged diffuse bruising and swelling of the surrounding skin and axilla. LP 8 62/M CRTD WD, PD 4 M IHD: 4 VD, AF, HPT, DM Recurrent VT/VF. Echo 25–30% Complicated with SSI, required explantation. TP 9 76/M PPM IBE, NPD 3 M HPT/ DM/ CHB TP 10 72/M PPM IBE 4 Y Lymphoma, DM Sinoatrial dysfunction, 2VD. Echo 35–40% Seroma, drained. TP 11 66/M CRTP Hematoma (traumatic) with WD 1 Y HPT, AF, DCM. Echo 40–45%. RWMA with hypokinesia. TP 12 77/F CRTD ILE 5 Y DCM, CKD, DM. Echo 33%. LP 13 71/M ICD SSI 1 M IHD, AF. Echo 55% TP 14 62/M ICD SSI 9 M HPT. Echo 53%. Hypokinetic post-wall. TP 3 Results From June 2023 to August 2025, we treated 14 patients with pacemaker-related complications, including wire and device erosion, necrotic skin, and infections. Devices included five ICDs, six PPMs, two CRTDs, and one CRTP. Patient ages ranged from 27 to 78 years, with symptom onset occurring between three weeks and seven years after implantation. The surgical procedure lasted between 60 and 200 minutes. The majority of the time was spent carefully dissecting to free up the wires safely. The most common presentation was implant body extrusion (n = 5). Three patients presented with non-purulent discharge. Two patients had implant lead extrusion. Two patients had skin necrosis with/without extrusion. One patient had a trauma near the implant, causing a hematoma and a minor dehiscence. The lowest ejection fraction in our patients was 25% (n = 3). Two patients presented with purulent discharge, in which one of these also had an infected hematoma, which was causing frequent VT storms (which necessitated urgent surgery). Two had non-purulent discharge. The surgical approach for entry to the subpectoral plane was nine transpectoral and five lateral pectoral approaches. 3.1 Post Operative Complications. One patient had implant migration to the axilla. It was corrected with replanting and reinforcing the lateral border of the pectoralis muscle. One patient (patient 8) had a surgical site infection, which necessitated explanting the device. One patient (patient 7) had prolonged bruising lasting up to 2 weeks, which was anticipated due to anti-coagulant dependency. The bruises resolved conservatively. One patient (patient 10) developed a seroma. It was resolved with surgical drainage. Otherwise, there were no mortalities, no intra-operative anaesthetic complications, and no other morbidities. At the time of writing, all patients were still alive and well. Based on the number of patients above, we calculate a 93% successful salvage rate. 4 Discussions Salvaging an infected cardiac implantable electronic device (CIED) in the context of an isolated pocket infection, without evidence of systemic infection (e.g., endocarditis or septicaemia), may be considered when the benefits outweigh the risks. Several factors must be taken into consideration, including the patient's long-term prognosis and survival, financial status, and clinical risks. In our experience, salvaging the devices yields good outcomes for most patients, demonstrating the feasibility of this option.[ 4 ] [ 5 , 6 ]Creating a subpectoral pocket is essentially utilising a 'muscle flap' with all its inherent properties. It is well established in previous studies that muscle flaps are superior in bacterial suppression and demonstrate superior blood flow.[ 7 ] Compared to the fasciocutaneous flap (which also compares to the subcutaneous / prepectoral pocket). This subpectoral approach has also been well established and widely used in breast implant surgeries.[ 8 ]. When comparing subcutaneous to subpectoral pockets, there was a significant decrease in complications in the subpectoral type, or subpectoral derivatives, notably decreased seroma, fewer late surgical site infections, less cellulitis, less delayed wound healing, and fewer implant or expander losses.[ 8 ]. Regarding the usage of drains, this is not usually required. 4.1 Lateral Pectoral vs Transpectoral Approach The surgical team decided on the surgical approach based on basic surgical principles of minimising trauma, minimising bleeding, and function sparing of the pectoralis major muscle. The transpectoral approach would render the entry to the subpectoral plane with more intramuscular perforators and branches, which may not be easily secured with normal cautery, especially with patients on anticoagulation or blood thinners. However, the advantage of this approach was reduced interplanar dissection, allowing the surgery to proceed directly to the subpectoral destination. Therefore, this approach would also bury more wires under the muscle. In comparison, the lateral pectoral approach involves a slightly longer dissection, which brings the device wires to wrap around the muscle. We find that this would be a difference of wire length of 8–12 cm. With the lateral pectoral approach, the suprafascial plane is dissected until the lateral pectoral border, where only 2–3 visible branches of the Lateral Pectoral Artery or Lateral Intercostal Arteries were seen and safely retracted away, or securely ligated. In our experience, we believe this was the best approach when the patient had higher bleeding tendencies due to anticoagulation or blood-thinning medications, etc. However, the dissection would involve a longer path, which would render the wires to more subcutaneous exposure as mentioned above. This may not be ideal in thin patients. To counteract the risk, we bury the wire either under the deep pectoral fascia or occasionally create grooves between the muscle fibres to achieve the same effect. In 2 of our cases where the transpectoral approach was taken, we identified the groove between the clavicular and sternocostal heads of the pectoralis major muscle, where the intramuscular network was less prominent. We accorded ourselves an areolar, less vascular plane of entry. This was indeed helpful, but dissecting to locate the groove may be excessive. When attempting this approach, we were mindful and cognizant of the Pectoral Branch of the Thoracoacromion Artery, which was within a 2 cm radius of the midclavicular line. Our patient who developed post-salvage surgical site infection was from the transpectoral group. We believe this may have been due to the over-coiling of the wires, which we had to conserve in a tight bundle, resulting in more physical dead space surface areas. Retrospectively, we believe that the complication could have been avoided if we had coiled the wires in a more radial and wider spaced arrangement. 5 Conclusion From the data above, the authors believe that combining knowledge of complex wounds with the utilisation of inherent muscle flap properties can salvage CIEDs in patients with erosions or localised infections in the subpectoral pocket, making it a viable option that will lead to better costs and resource management. Abbreviations AF Atrial Fibrillation AR Aortic Regurgitation AV Atrioventricular CIED Cardiac Implantable Electronic Device CKD Chronic Kidney Disease CRTD Cardiac Resynchronisation Therapy with Defibrillator CRTP Cardiac Resynchronisation Therapy with Pacemaker DM Diabetes Mellitus DCM Dilated Cardiomyopathy Echo Echocardiography GA General Anaesthesia HF Heart Failure HPT Hypertension ICD Implantable Cardioverter-Defibrillator IHD Ischemic Heart Disease ILE Implant Lead Extrusion IBE Implant Body Extrusion LP Lateral Pectoral approach NPD Non-purulent Discharge PPM Permanent Pacemaker RWMA Regional Wall Motion Abnormality SSI Surgical Site Infection TP Transpectoral approach TOF Tetralogy of Fallot VF Ventricular Fibrillation VT Ventricular Tachycardia WD Wound Dehiscence. Declarations Ethics Approval This study was reviewed and approved by the Sektretariat Etika Penyelidikan Universiti Kebangsaan Malaysia (SEPUKM, REF: JEP-2025-801). The committee determined that formal patient consent and additional ethical approval were waived, as this was a retrospective review of existing patient records with no direct patient intervention. The study was conducted in accordance with the principles of the Declaration of Helsinki. Consent to Participate The requirement for informed consent to participate was waived by Sektretariat Etika Penyelidikan Universiti Kebangsaan Malaysia (SEPUKM, REF: JEP-2025-801). This study was retrospective in nature, and patient data were anonymised before analysis. Consent for Publication Written informed consent for publication of the clinical images was obtained from the patients. The consent documents are not publicly available due to hospital confidentiality policies but are available from the corresponding author on reasonable request and may be provided to the editor if required. Availability of Data and Materials The datasets generated and/or analysed during the current study are not publicly available due to hospital confidentiality policies but are available from the corresponding author on reasonable request. Competing Interests The authors declare that they have no competing interests. Funding The authors received no financial support for the research, authorship, and/or publication of this article. Authors' Contributions PYW Adzim: data collection, manuscript drafting. RA Mukhlis: conceptualisation, methodology, manuscript editing, corresponding author. AZ Mat Saad: surgical supervision, critical revision. MA Raffali & KM Rahaman: cardiology consultation and patient referral. AF Abdul Shokri: anaesthesia support and perioperative optimisation. ASA Mohamed Zahari: surgical assistance and figure preparation. All authors reviewed and approved the final manuscript. Acknowledgements The authors thank the staff of the Plastic and Reconstructive Surgery Unit and the Cardiology Unit at Hospital Canselor Tuanku Muhriz for their collaboration and support in managing the patients described in this study. References Shoukri N, et al. Real-world survey of post-operative cardiac implantable electronic device (CIED) complications reported by the electrophysiology team in 2022. J Interventional Cardiac Electrophysiol. 2023;66(7):1567–9. Bonawitz SC. Management of exposure of cardiac pacemaker systems. Ann Plast Surg. 2012;69(3):292–5. Simpson AM, et al. Salvage of threatened cardiovascular implantable electronic devices: case series and review of literature. Ann Plast Surg. 2018;81(3):340–3. Sohail MR et al. Infective endocarditis complicating permanent pacemaker and implantable cardioverter-defibrillator infection . in Mayo Clinic Proceedings . 2008. Elsevier. Jones IV. Large, single-center, single-operator experience with transvenous lead extraction: outcomes and changing indications. Heart rhythm. 2008;5(4):520–5. Furman R, et al. Infected permanent cardiac pacemaker: management without removal. Ann Thorac Surg. 1972;14(1):54–8. Gosain A, et al. A study of the relationship between blood flow and bacterial inoculation in musculocutaneous and fasciocutaneous flaps. Plast Reconstr Surg. 1990;86(6):1152–62. Talwar AA, et al. Prepectoral versus submuscular implant-based breast reconstruction: a matched-pair comparison of outcomes. Plast Reconstr Surg. 2024;153(2):e281–90. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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12:08:46","extension":"xml","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":53187,"visible":true,"origin":"","legend":"","description":"","filename":"9ce09c41718b42b1861fc45dfd30d1fe1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7521607/v1/e147e9a661304da60af2b666.xml"},{"id":94762054,"identity":"0f7bf8ce-a7d4-478e-8014-5dc08065dd26","added_by":"auto","created_at":"2025-10-30 12:08:46","extension":"html","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":63701,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7521607/v1/02d8ec5d6faee1bbad9b1b95.html"},{"id":94762051,"identity":"217830ee-9888-4bd5-b11e-e3e354cbe802","added_by":"auto","created_at":"2025-10-30 12:08:46","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":705519,"visible":true,"origin":"","legend":"\u003cp\u003eTranspectoral approach for reimplantation of CIED\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7521607/v1/0726611d74c2e87639bfa669.png"},{"id":94762063,"identity":"e3467f14-6b87-42df-a887-894c4f1dd608","added_by":"auto","created_at":"2025-10-30 12:08:48","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":711604,"visible":true,"origin":"","legend":"\u003cp\u003eLateral pectoral approach for reimplantation of CIED\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7521607/v1/a04c1f8c9be73d1a48c473fa.png"},{"id":94762068,"identity":"bdb15244-c732-4308-be4a-f5a4efa025cc","added_by":"auto","created_at":"2025-10-30 12:08:48","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":429681,"visible":true,"origin":"","legend":"\u003cp\u003eCIED explanted from left chest wall\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7521607/v1/0d3ceb66d9b93200e9785ba6.png"},{"id":94762105,"identity":"804ab800-2c47-497a-896f-a7513cadf5ca","added_by":"auto","created_at":"2025-10-30 12:08:49","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":440760,"visible":true,"origin":"","legend":"\u003cp\u003eIncision extend laterally and inferiorly\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7521607/v1/17c3449a0ac024db42e38a7c.png"},{"id":94762106,"identity":"eab352f1-831a-4049-a624-23998c0b3ee8","added_by":"auto","created_at":"2025-10-30 12:08:50","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":465164,"visible":true,"origin":"","legend":"\u003cp\u003eSkin closed subcuticular\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-7521607/v1/0a55e52673ff3501b8decfb5.png"},{"id":106396095,"identity":"9d89f46b-7d16-4165-91ab-9c2a7fdb8f2b","added_by":"auto","created_at":"2026-04-08 07:59:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4565309,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7521607/v1/694857b4-9a79-4deb-9950-72b3351e80f3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Salvaging the Cardiac Implantable Electronic Device: Transpectoral versus Lateral Pectoral Approach","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eAnnually, 1.2\u0026ndash;1.4\u0026nbsp;million CIEDs are implanted globally with various indications. Standard devices with leads are still required, especially for patients who require defibrillation and physiological pacing. The complications related to the insertion of the implant itself could sometimes be catastrophic to the patients, especially involving infection of the device. Infections and lead erosions are rare, at about 2%[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. When complications arise, most centres advocate for the removal of the implant and reinsertion of a new device to avoid recurrences.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, in certain situations, this may increase risks associated with large vessel re-puncturing. And for certain parts of the world, the astronomic costs may be too significant to bear.\u003c/p\u003e\u003cp\u003eSubpectoral repositioning of the CIED has been known since the 1950s. However, certain risks were reported by practitioners, namely recurrence and infection.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Salvaging an implant is considered high risk, due to known experiences where surgical site infections may be too high. With a deeper understanding of biofilms and the role of muscular flaps in mitigating infections, we integrate complex wound management sciences with meticulous surgical techniques to achieve high success rates in salvaging CIEDs.\u003c/p\u003e"},{"header":"2 Methods","content":"\u003cp\u003e This study was conducted and reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines and adhered to the principles outlined in the Declaration of Helsinki regarding research involving human subjects. We retrospectively reviewed patient records from July 2023 to August 2025. Patients referred to the Plastic and Reconstructive Surgery Unit of Hospital Canselor Tuanku Muhriz by cardiologists or electrophysiologists for implant-related complications were assessed. Reasons for referral included wire exposure, implant body exposure, non-purulent discharge, pus discharge, and life-threatening situations of infection-related implant stimulation.\u003c/p\u003e\u003cp\u003eA multidisciplinary approach was taken, involving the electrophysiologist, anaesthesiologist, and plastic surgeon. Key factors considered during multidisciplinary discussions included:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003ePros and cons of salvaging the implant for the patient, compared to extraction.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eOptimisation of co-morbidities.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eAnticipation of complications.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eOngoing anticoagulative therapy.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003ePost-operative disposition.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003ePreoperatively, systemic antibiotics were initiated to help contain the infection locally at the peri-implant site. An assessment of the extent of inflammation and damage was made to determine the anatomy involved and whether the infection had spread through natural planes. The anatomical presence of the pectoralis major muscle and clinical judgment of its thickness were assessed subjectively by asking the patient to press their hand against their waist while palpating for the muscle bulk. No preoperative imaging was required for our patients.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Surgical Method\u003c/h2\u003e\u003cp\u003ePatients were under general anaesthesia, unless specified.\u003c/p\u003e\u003cp\u003eThe cardiologist and technician were prepared for device reassessment and interrogation to make sure the device was functioning normally prior to the procedure.\u003c/p\u003e\u003cp\u003eIncision was designed to allow access to the implant and to excise the diseased skin and tissues. This was usually around the site of skin erosion/ inflammation. The decision of incision was based on these factors:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eProximity to the exposed implant part.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eProximity to the main implant body.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003ePalpable induration/ collection.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eA minimal access approach was taken, limiting the incision size. This usually corresponded to the least diameter of the implant. Necrotic, scarred, or senescent skin and tissue were excised in toto. Only scalpel and cold steel surgery with minimal use of bipolar cautery was used. The wires were carefully teased off all fibrosis until about 2-3cm from the subclavian entry point. The pacemaker body was retrieved and scrubbed with a chlorhexidine-soaked gauze until all visible debris was removed. Then, the body and wires were immersed sequentially in povidone 5% (100 mL), chlorhexidine gluconate 4% (100 mL), and then, lastly, in gentamicin 80mg diluted in 100 mL of normal saline, for 5 minutes each. While awaiting the immersion time, the surgeon started on the dissection of the pectoralis major pocket. This was created either via transpectoral approach or a lateral pectoral approach, as described below:\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e\u003cb\u003e2.2 Transpectoral Approach\u003c/b\u003e (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/h2\u003e\u003cp\u003eA muscle-splitting action was done through the pectoralis major, with only blunt dissection. No muscle cutting was required. Small bleeding muscle capillaries were cauterized with bipolar cautery. Using larger retractors and finger dissection, the plane between the pectoralis major and pectoralis minor muscles was identified. An exact-size pocket was created.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e\u003cb\u003e2.3 Lateral Pectoral Approach\u003c/b\u003e (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/h2\u003e\u003cp\u003eFrom the original subcutaneous pocket, the skin incision was extended to the left anterior axillary line (see Figs.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The dissection was extended in the pre-deep fascial plane to the lateral border of the pectoralis major muscle. This was around 5 cm below the axilla. Blunt dissection was then employed to access the subpectoral plane, which is the area between the pectoralis major and pectoralis minor muscles, creating a pocket of about 10 cm. Occasionally, branches of the lateral thoracic artery were encountered, and they could usually be retracted out of the way without being ligated.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe pacemaker body was then transferred to the subpectoral pocket and secured with monocryl 3\u0026thinsp;\u0026minus;\u0026thinsp;0 sutures using a round-body needle. Entrance to the pocket was approximated with 3\u0026thinsp;\u0026minus;\u0026thinsp;0 monocryl sutures at the muscle level. The wires were tucked maximally in the pocket, and any extra-pectoral wires were fixed and sutured under the pectoral fascia to reduce effacement.\u003c/p\u003e\u003cp\u003eWound was closed in layers, usually pectoral fascia, deep dermal, and skin suture.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePatient presentation, with subpectoral approaches. WD: Wound Dehiscence, IBE: Implant Body extrusion, ILE: Implant Lead Extrusion, PD: Purulent Discharge, NPD: Non-purulent Discharge, SSI: Surgical Site Infection, ICD: Implantable Cardioverter-Defibrillator. PPM: Permanent Pacemaker, CRTD: Cardiac resynchronisation therapy with pacemaker, CRTD: Cardiac Resynchronisation Therapy with Defibrillator, LP: Lateral Pectoral, TP: Transpectoral. IHD: Ischemic heart disease, HF: Heart Failure, 3VD: three vessels disease, HPT: Hypertension, AF: Atrial Fibrillation, DCM: Dilated Cardiomyopathy, CKD: Chronic Kidney Disease, DM: Diabetes Mellitus, VD: Vessel disease, VT: Ventricular Tachycardia, VF: Ventricular fibrillation, TOF: Tetralogy of Fallot, TR: Tricuspid Regurgitation, PR: Pulmonic Artery Regurgitation,\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAge/\u003c/p\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eImplant type\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePresentation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTime from Implant to revision\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eMed background\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNote. Cases done under GA unless specified\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eSurgical approach\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e78/F\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eICD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNecrotic skin, VT storm PD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1 M\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eIHD, HF, PCI LAD, AF, RA, Echo 41%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eSurgery under regional block, Postoperative vacuum dressing applied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eLP\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27/M\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePPM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eILE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7 Y\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eCHB, PDA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eChange of device on the table\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eLP\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e69/M\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePPM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSkin thinning on PPM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1 M\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eIHD, 3VD, Mobitz I AV block. Echo 50\u0026ndash;55%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eOne month later, implant migration occurred along the anterior axillary line, and the implant was revised.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eLP\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e73/M\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePPM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIBE, NPD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7 W\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eHPT, IHD, 3rd deg AV block, mild AR. Echo 67%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eTP\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e52/M\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eICD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNecrotic skin.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3 W\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eHPT/DM, RWMA, Rec VT. Echo 34% with global hypokinesia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eTP\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e57/M\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eICD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIBE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2 M\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eDCM, VT,\u003c/p\u003e\u003cp\u003eCKD. Echo 25%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eTP\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e67/M\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePPM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIBE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2 Y\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTOF, TR, PR, AR, residual VSD,\u003c/p\u003e\u003cp\u003eMechanical aVR SJM,\u003c/p\u003e\u003cp\u003ePermanent AF with VVIR.\u003c/p\u003e\u003cp\u003eOn warfarin.\u003c/p\u003e\u003cp\u003eEcho 55%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eProlonged diffuse bruising and swelling of the surrounding skin and axilla.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eLP\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e62/M\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCRTD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWD, PD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4 M\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eIHD: 4 VD, AF, HPT, DM\u003c/p\u003e\u003cp\u003eRecurrent VT/VF. Echo 25\u0026ndash;30%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eComplicated with SSI, required explantation.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eTP\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e76/M\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePPM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIBE, NPD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3 M\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eHPT/ DM/ CHB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eTP\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e72/M\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePPM\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIBE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4 Y\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eLymphoma, DM\u003c/p\u003e\u003cp\u003eSinoatrial dysfunction, 2VD. Echo 35\u0026ndash;40%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eSeroma, drained.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eTP\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e66/M\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCRTP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHematoma (traumatic) with WD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1 Y\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eHPT, AF, DCM.\u003c/p\u003e\u003cp\u003eEcho 40\u0026ndash;45%. RWMA with hypokinesia.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eTP\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e77/F\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCRTD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eILE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5 Y\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eDCM, CKD, \u003c/p\u003e\u003cp\u003eDM. Echo 33%.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eLP\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e71/M\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eICD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSSI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1 M\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eIHD, AF. Echo 55%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eTP\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e62/M\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eICD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSSI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9 M\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eHPT. Echo 53%. Hypokinetic post-wall.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eTP\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"3 Results","content":"\u003cp\u003eFrom June 2023 to August 2025, we treated 14 patients with pacemaker-related complications, including wire and device erosion, necrotic skin, and infections. Devices included five ICDs, six PPMs, two CRTDs, and one CRTP. Patient ages ranged from 27 to 78 years, with symptom onset occurring between three weeks and seven years after implantation. The surgical procedure lasted between 60 and 200 minutes. The majority of the time was spent carefully dissecting to free up the wires safely.\u003c/p\u003e\u003cp\u003eThe most common presentation was implant body extrusion (n\u0026thinsp;=\u0026thinsp;5). Three patients presented with non-purulent discharge. Two patients had implant lead extrusion. Two patients had skin necrosis with/without extrusion. One patient had a trauma near the implant, causing a hematoma and a minor dehiscence.\u003c/p\u003e\u003cp\u003eThe lowest ejection fraction in our patients was 25% (n\u0026thinsp;=\u0026thinsp;3).\u003c/p\u003e\u003cp\u003eTwo patients presented with purulent discharge, in which one of these also had an infected hematoma, which was causing frequent VT storms (which necessitated urgent surgery). Two had non-purulent discharge.\u003c/p\u003e\u003cp\u003eThe surgical approach for entry to the subpectoral plane was nine transpectoral and five lateral pectoral approaches.\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Post Operative Complications.\u003c/h2\u003e\u003cp\u003eOne patient had implant migration to the axilla. It was corrected with replanting and reinforcing the lateral border of the pectoralis muscle.\u003c/p\u003e\u003cp\u003eOne patient (patient 8) had a surgical site infection, which necessitated explanting the device.\u003c/p\u003e\u003cp\u003eOne patient (patient 7) had prolonged bruising lasting up to 2 weeks, which was anticipated due to anti-coagulant dependency. The bruises resolved conservatively.\u003c/p\u003e\u003cp\u003eOne patient (patient 10) developed a seroma. It was resolved with surgical drainage.\u003c/p\u003e\u003cp\u003eOtherwise, there were no mortalities, no intra-operative anaesthetic complications, and no other morbidities. At the time of writing, all patients were still alive and well. Based on the number of patients above, we calculate a 93% successful salvage rate.\u003c/p\u003e\u003c/div\u003e"},{"header":"4 Discussions","content":"\u003cp\u003eSalvaging an infected cardiac implantable electronic device (CIED) in the context of an isolated pocket infection, without evidence of systemic infection (e.g., endocarditis or septicaemia), may be considered when the benefits outweigh the risks. Several factors must be taken into consideration, including the patient's long-term prognosis and survival, financial status, and clinical risks. In our experience, salvaging the devices yields good outcomes for most patients, demonstrating the feasibility of this option.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]Creating a subpectoral pocket is essentially utilising a 'muscle flap' with all its inherent properties. It is well established in previous studies that muscle flaps are superior in bacterial suppression and demonstrate superior blood flow.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] Compared to the fasciocutaneous flap (which also compares to the subcutaneous / prepectoral pocket).\u003c/p\u003e\u003cp\u003eThis subpectoral approach has also been well established and widely used in breast implant surgeries.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. When comparing subcutaneous to subpectoral pockets, there was a significant decrease in complications in the subpectoral type, or subpectoral derivatives, notably decreased seroma, fewer late surgical site infections, less cellulitis, less delayed wound healing, and fewer implant or expander losses.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRegarding the usage of drains, this is not usually required.\u003c/p\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e4.1 Lateral Pectoral vs Transpectoral Approach\u003c/h2\u003e\u003cp\u003eThe surgical team decided on the surgical approach based on basic surgical principles of minimising trauma, minimising bleeding, and function sparing of the pectoralis major muscle.\u003c/p\u003e\u003cp\u003eThe transpectoral approach would render the entry to the subpectoral plane with more intramuscular perforators and branches, which may not be easily secured with normal cautery, especially with patients on anticoagulation or blood thinners. However, the advantage of this approach was reduced interplanar dissection, allowing the surgery to proceed directly to the subpectoral destination. Therefore, this approach would also bury more wires under the muscle. In comparison, the lateral pectoral approach involves a slightly longer dissection, which brings the device wires to wrap around the muscle. We find that this would be a difference of wire length of 8\u0026ndash;12 cm.\u003c/p\u003e\u003cp\u003eWith the lateral pectoral approach, the suprafascial plane is dissected until the lateral pectoral border, where only 2\u0026ndash;3 visible branches of the Lateral Pectoral Artery or Lateral Intercostal Arteries were seen and safely retracted away, or securely ligated. In our experience, we believe this was the best approach when the patient had higher bleeding tendencies due to anticoagulation or blood-thinning medications, etc. However, the dissection would involve a longer path, which would render the wires to more subcutaneous exposure as mentioned above. This may not be ideal in thin patients. To counteract the risk, we bury the wire either under the deep pectoral fascia or occasionally create grooves between the muscle fibres to achieve the same effect.\u003c/p\u003e\u003cp\u003eIn 2 of our cases where the transpectoral approach was taken, we identified the groove between the clavicular and sternocostal heads of the pectoralis major muscle, where the intramuscular network was less prominent. We accorded ourselves an areolar, less vascular plane of entry. This was indeed helpful, but dissecting to locate the groove may be excessive. When attempting this approach, we were mindful and cognizant of the Pectoral Branch of the Thoracoacromion Artery, which was within a 2 cm radius of the midclavicular line.\u003c/p\u003e\u003cp\u003eOur patient who developed post-salvage surgical site infection was from the transpectoral group. We believe this may have been due to the over-coiling of the wires, which we had to conserve in a tight bundle, resulting in more physical dead space surface areas. Retrospectively, we believe that the complication could have been avoided if we had coiled the wires in a more radial and wider spaced arrangement.\u003c/p\u003e\u003c/div\u003e"},{"header":"5 Conclusion","content":"\u003cp\u003eFrom the data above, the authors believe that combining knowledge of complex wounds with the utilisation of inherent muscle flap properties can salvage CIEDs in patients with erosions or localised infections in the subpectoral pocket, making it a viable option that will lead to better costs and resource management.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAtrial Fibrillation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAortic Regurgitation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAtrioventricular\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCIED\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCardiac Implantable Electronic Device\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCKD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eChronic Kidney Disease\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCRTD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCardiac Resynchronisation Therapy with Defibrillator\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCRTP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCardiac Resynchronisation Therapy with Pacemaker\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDiabetes Mellitus\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDCM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDilated Cardiomyopathy\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEcho\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEchocardiography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGeneral Anaesthesia\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHeart Failure\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHPT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHypertension\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eICD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eImplantable Cardioverter-Defibrillator\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIHD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIschemic Heart Disease\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eILE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eImplant Lead Extrusion\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIBE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eImplant Body Extrusion\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eLP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLateral Pectoral approach\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNPD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNon-purulent Discharge\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePPM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePermanent Pacemaker\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRWMA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRegional Wall Motion Abnormality\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSSI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSurgical Site Infection\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTranspectoral approach\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTOF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTetralogy of Fallot\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eVF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eVentricular Fibrillation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eVT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eVentricular Tachycardia\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWound Dehiscence.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was reviewed and approved by the \u003cem\u003eSektretariat Etika Penyelidikan Universiti Kebangsaan Malaysia\u003c/em\u003e (SEPUKM, REF: JEP-2025-801). The committee determined that formal patient consent and additional ethical approval were waived, as this was a retrospective review of existing patient records with no direct patient intervention. The study was conducted in accordance with the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe requirement for informed consent to participate was waived by \u003cem\u003eSektretariat Etika Penyelidikan Universiti Kebangsaan Malaysia\u003c/em\u003e (SEPUKM, REF: JEP-2025-801). This study was retrospective in nature, and patient data were anonymised before analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication of the clinical images was obtained from the patients. The consent documents are not publicly available due to hospital confidentiality policies but are available from the corresponding author on reasonable request and may be provided to the editor if required.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to hospital confidentiality policies but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no financial support for the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePYW Adzim: data collection, manuscript drafting.\u003c/p\u003e\n\u003cp\u003eRA Mukhlis: conceptualisation, methodology, manuscript editing, corresponding author.\u003c/p\u003e\n\u003cp\u003eAZ Mat Saad: surgical supervision, critical revision.\u003c/p\u003e\n\u003cp\u003eMA Raffali \u0026amp; KM Rahaman: cardiology consultation and patient referral.\u003c/p\u003e\n\u003cp\u003eAF Abdul Shokri: anaesthesia support and perioperative optimisation.\u003c/p\u003e\n\u003cp\u003eASA Mohamed Zahari: surgical assistance and figure preparation.\u003c/p\u003e\n\u003cp\u003eAll authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the staff of the Plastic and Reconstructive Surgery Unit and the Cardiology Unit at Hospital Canselor Tuanku Muhriz for their collaboration and support in managing the patients described in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eShoukri N, et al. Real-world survey of post-operative cardiac implantable electronic device (CIED) complications reported by the electrophysiology team in 2022. J Interventional Cardiac Electrophysiol. 2023;66(7):1567\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBonawitz SC. Management of exposure of cardiac pacemaker systems. Ann Plast Surg. 2012;69(3):292\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSimpson AM, et al. Salvage of threatened cardiovascular implantable electronic devices: case series and review of literature. Ann Plast Surg. 2018;81(3):340\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSohail MR et al. \u003cem\u003eInfective endocarditis complicating permanent pacemaker and implantable cardioverter-defibrillator infection\u003c/em\u003e. in \u003cem\u003eMayo Clinic Proceedings\u003c/em\u003e. 2008. Elsevier.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJones IV. Large, single-center, single-operator experience with transvenous lead extraction: outcomes and changing indications. Heart rhythm. 2008;5(4):520\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFurman R, et al. Infected permanent cardiac pacemaker: management without removal. Ann Thorac Surg. 1972;14(1):54\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGosain A, et al. A study of the relationship between blood flow and bacterial inoculation in musculocutaneous and fasciocutaneous flaps. Plast Reconstr Surg. 1990;86(6):1152\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTalwar AA, et al. Prepectoral versus submuscular implant-based breast reconstruction: a matched-pair comparison of outcomes. Plast Reconstr Surg. 2024;153(2):e281\u0026ndash;90.\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":"Cardiac Implantable Electronic Device (CIED), Pacemaker Complications, Device Salvage, Transpectoral Reimplantation, Lateral Pectoral Approach Reimplantation","lastPublishedDoi":"10.21203/rs.3.rs-7521607/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7521607/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eCardiac implantable electronic devices (CIEDs) are a vital therapeutic measure to keep arrhythmic patients from heart failure or death. Complications of insertions are rare but may present as implant body erosions, wire erosions, infection, and chronic subclinical infection. Whilst most centres advocate device extraction and new device implantation, salvaging the implant can bring numerous benefits. We describe our experience with patients who experienced complications, for whom their devices were salvaged and reimplanted subpectorally, achieving high success rates. We also compare the differences of the transpectoral and the lateral pectoral approaches, and discuss the challenges and pre-emptive measures taken.\u003c/p\u003e","manuscriptTitle":"Salvaging the Cardiac Implantable Electronic Device: Transpectoral versus Lateral Pectoral Approach","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-30 12:08:28","doi":"10.21203/rs.3.rs-7521607/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":"a6168724-e605-4b2b-b9da-c36e075a67e7","owner":[],"postedDate":"October 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-08T07:57:37+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-30 12:08:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7521607","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7521607","identity":"rs-7521607","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}