Retained Temporary Epicardial Pacing Wire Disguised as a Cutaneous Nodule

Summary: A 76-year-old female with a past medical history of breast cancer (status post mastectomy and radiation therapy) and mitral and tricuspid valve regurgitation (status post open-heart surgery for valve repair and replacement) presented to dermatology with a painful, non-healing skin lesion of the upper abdomen. She reported a three-year history of an enlarging “pimple” that progressively became more painful. On exam, the patient had an erythematous nodule with surrounding erythema, overlying crust, and minimal purulent drainage. The differential diagnosis included nonmelanoma skin cancer, cutaneous metastasis/Sister Mary Joseph nodule, pyoderma gangrenosum, and furuncle. A shave biopsy was attempted but was halted when a white wire was visualized at the base of the biopsy. Upon discussion with cardiothoracic surgery, it was determined that this wire was a retained temporary epicardial pacing wire (TEPW), which was placed at the time of the patient’s open-heart surgery three years prior. A radiopaque linear structure was retrospectively identified on abdominal CT imaging obtained one-month post-operatively, corresponding to the location of the cutaneous nodule seen on exam. Cardiothoracic surgery performed an elliptical excision of the cutaneous nodule down to the subcutaneous fat. Resistance was met when external traction was applied to the wire. Thus, the pacing wire was cut flush to the skin surface, removing a piece of wire approximately 4 cm in size, and the site was closed primarily. The patient healed well after partial wire removal without further complications. TEPWs are routinely placed during cardiac surgery to help manage postoperative arrythmias. The wires are typically removed with gentle traction a few days post-operatively once normal cardiac rhythm has been reestablished. In the setting of difficult wire removal or patients on anticoagulation, the wires are cut flush to the skin surface to prevent hemorrhage and tissue damage. In most cases, the wire retracts into the deeper subcutaneous tissue, without further complication. However, in some instances, the retained TEPW can become superficial, resulting in a foreign body granuloma. Dermatologists play an important role in recognizing the cutaneous complications of retained TEPWs, including foreign body granulomas, cutaneous erosions, sinus tracts and fistulas, and local infections. It is important to consider retained TEPWs in the differential diagnosis for non-healing, erythematous cutaneous nodules that present on the upper abdomen, often adjacent to a sternotomy scar in patients with a history of cardiac surgery.