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Intrathoracic impedance monitoring is used to guide management of congestive heart failure. We describe a marked shift in intrathoracic impedance because of a pocket abscess. A 69-year-old male with an active pectoral implantable cardioverter-defibrillator (ICD) (Medtronic, Minneapolis, MN), an abandoned 23-year-old abdominal ICD, and a tunneled transvenous lead from the abdomen through the ipsilateral subclavian vein contiguous with both devices presented with frank abdominal ICD infection and epicardial patch infection. The abdominal system and epicardial leads were removed by abdominal incision and sternotomy, and the aforementioned transvenous lead was cut below and left to retract into the pectoral pocket. The patient was treated with a course of antibiotics and discharged. Four months later he presented with persistent swelling and drainage from his pectoral ICD pocket. The patient underwent explant of the device and extraction of the existing three transvenous leads, with the discovery of frank pus and an abscess cavity in the device pocket. Device interrogation showed an abrupt and persistent decrease in the intrathoracic impedance (OptiVol, Medtronic, Minneapolis, MN) correlating with the time of abdominal device removal. There were no signs or evidence of congestive heart failure. All other impedance measurements (right ventricle [RV], RV high voltage [HV], superior vena cava [HV]) were unchanged. Given that the intrathoracic impedance is measured between the ICD generator and the RV coil and can be impacted by fluid in the device pocket, we hypothesize that the finding of decreased intrathoracic impedance was a consequence of a pocket abscess. We considered that the change could have been a result of the sternotomy but dismissed this because of the absence of any other changes in lead impedance measurements. Intrathoracic impedance is typically used for monitoring of heart failure, but a pocket abscess should be considered in the differential diagnosis in the setting of device infection and associated symptoms.

Intrathoracic Impedance Measurement Abnormality as a Consequence of ICD Pocket Abscess: A New Differential Diagnosis