What is the best course of action for a patient with right scapula pain and cardiac leads (implantable cardioverter-defibrillator or pacemaker leads)?

Right Scapula Pain with Cardiac Leads: Evaluation and Management

The primary concern in a patient with right scapula pain and cardiac leads is to rule out device infection, lead complications, or lead-related endocarditis, which require urgent complete device and lead removal. 1, 2

Immediate Diagnostic Priorities

Assess for Device Infection

• Examine the device pocket site for signs of infection including erythema, warmth, swelling, purulent drainage, device erosion, skin adherence, or chronic draining sinus 1, 2
• Obtain blood cultures immediately if fever is present or if there are any signs suggesting systemic infection 1
• Order transesophageal echocardiography (TEE) if blood cultures are positive or if there is clinical suspicion for lead-associated masses or valvular endocarditis, as TEE is superior to transthoracic echo for detecting lead vegetations 1

Evaluate for Lead Complications

• Obtain chest radiograph to assess for lead displacement, lead fracture, or Twiddler's syndrome (coiling of leads around the device) 3
• Check device interrogation to identify sensing abnormalities, pacing threshold changes, or impedance changes that may indicate lead malfunction 1, 4
• Consider lead perforation if pain is acute and associated with pericardial symptoms, though this typically presents with chest rather than scapular pain 4

Rule Out Musculoskeletal Causes

• Evaluate for snapping scapula syndrome, which presents with pain at the superomedial border of the scapula, audible/palpable crepitus with overhead activities, and is common in young active patients 5
• This diagnosis becomes more likely if device examination is normal, blood cultures are negative, and imaging shows no lead complications 5

Management Based on Findings

If Device Infection is Confirmed

Complete device and lead removal is mandatory and should occur within 3 days of diagnosis, as early extraction is associated with lower in-hospital mortality 1, 2, 6

Specific indications requiring immediate complete removal include: 1, 2, 6

• Pocket infection with abscess, erosion, or purulent drainage
• Positive blood cultures with Staphylococcus aureus (even without visible pocket infection)
• Lead or valvular endocarditis on TEE
• Persistent Gram-negative bacteremia despite appropriate antibiotics
• Occult bacteremia without other identified source

Antimicrobial therapy duration: 1, 2, 6

• Pocket infection only: 10-14 days after device removal
• Bloodstream infection: at least 14 days after device removal
• Complicated infection (endocarditis, septic thrombophlebitis): 4-6 weeks after removal

Reimplantation timing: 1, 2, 6

• Blood cultures must be negative for at least 72 hours before new device placement
• For valvular infection, delay reimplantation for at least 14 days after first negative blood culture
• Never reimplant on the same side—use contralateral side, iliac vein approach, or epicardial leads 1, 6
• Reassess whether patient still requires device therapy, as one-third to one-half may not need reimplantation 1, 2, 6

If Lead Complication is Identified

• Lead displacement or fracture: Device interrogation will show abnormal impedances or loss of capture; requires lead revision or replacement 1, 4
• Twiddler's syndrome: Requires operative intervention with lead repositioning and device pocket revision with deeper placement 3
• Lead perforation: May require surgical extraction if percutaneous removal is not feasible 1, 7

If Musculoskeletal Etiology is Confirmed

• Initial treatment is conservative: Physical therapy for scapular muscle strengthening, NSAIDs, and activity modification 5
• Corticosteroid injections may be used for both therapeutic and diagnostic purposes 5
• Surgical intervention (open or arthroscopic) is reserved for cases failing conservative management, especially if bony or soft-tissue mass is identified 5

Critical Pitfalls to Avoid

• Do not perform percutaneous aspiration of the device pocket for diagnostic purposes, as this is contraindicated 1
• Do not delay device removal to complete antibiotic courses if infection is confirmed—removal should proceed promptly 1, 6
• Do not use long-term suppressive antibiotics as an alternative to device removal in extraction candidates 1, 6
• Do not assume pain is musculoskeletal without first ruling out device-related complications, particularly infection, as this can be life-threatening if missed 1, 7