Editorial
The thinning of the skin and subcutaneous tissue above the pocket of cardiac implantable electronic devices (CIED) is an is an occasional phenomenon, which may have many reasons. The most frequently considered are: improper CIED implantation or re-implantation with too shallow design of the pocket, progressive weight loss (cachexia), but it can also be the temporary first visible stage or even first symptom of CIED pocket infection. In the observation of Yatomi et al. risk factors for skin thinning over the generator were: low BMI, low haemoglobin level, heart failure, malignancy and renal dysfunction. In this study, a retrospective analysis of clinical data from a group of 101 patients with an average lead dwell time of 95 months revealed no cases of pocket infections in patients with thinning of the skin over the generator. Authors recognised thinning of the skin in 17 patients (about 17%) which indicates, that the phenomenon is not so rare. According to our observations, too tight skin over a too tight and shallow pocket loses its elasticity and becomes less and less mobile, and after some time, progressive necrotic processes lead to a lack of protection against the penetration of bacteria. Patients with a shallow CIED pocket should be monitored by an electrocardiologist controlling the device (and performing follow-up). Changes in the colour of the skin towards blue or reddening, the appearance of pain or local warming, or the loss of skin sliding over the bed, means the probable beginning of infection, which is an indication for transvenous lead extraction (TLE). In patients with a very superficial generator site, without signs of infection, the possibility of deepening the pocket (so called surgical “plastic of the CIED pocket”) is sometimes considered. Theoretically, this type of procedure is possible, but the extremely shallow location of the unit is accompanied by the loop of the lead growing into the skin and the preparation of such leads is often associated with risk of their accidental damage as well as an increased risk of developing infectious complications. It should be emphasized that an excessively shallow pocket is not an indication for transvenous lead extraction. Its consequence in the form of bedsores (limited skin necrosis) or the next stage - purulent fistula over the pocket or loop of the lead - as an infectious complication - is already an indication for TLE ( Figure 1, Figure 2).