A temporary permanent pacemaker allowed a 31-year-old man with Lyme carditis to recover at home during the COVID-19 pandemic, avoiding prolonged hospitalization while his heart block resolved. The approach offers a safe middle ground between traditional temporary pacing and unnecessary permanent implants.

A New Approach to Lyme Carditis Management

Traditional management of Lyme carditis with high-degree heart block requires hospitalization with temporary transvenous pacing until antibiotics resolve the conduction abnormality. But the authors of a new case report suggest that for select patients, placement of a temporary permanent pacemaker (TPPM) may be an effective and safe alternative.

In their article, “A Practical Ambulatory Approach to Atrioventricular Block Secondary to Lyme Carditis,” Aromin and colleagues describe the case of a 31-year-old man who presented with heart block during the COVID-19 pandemic.

Case Presentation

The man had been suffering from multiple syncope episodes – a red flag symptom indicating severe cardiac conduction disturbance. His history was classic for Lyme disease:

• Embedded tick bite
• Fever and malaise following tick removal
• Multiple rashes consistent with erythema migrans
• Progressive cardiac symptoms

A temporary transvenous pacemaker (TTVP) was inserted via the right internal jugular vein upon admission. He was treated empirically with intravenous ceftriaxone – the correct approach when Lyme carditis is suspected, not waiting for test confirmation.

On day 5, the diagnosis of Lyme carditis was confirmed with positive test results. But rather than continuing conventional temporary pacing with prolonged hospitalization, clinicians made a strategic decision.

The Temporary Permanent Pacemaker Solution

“On day 6, a decision was made to implant a temporary permanent pacemaker (TPPM),” the authors wrote.

This approach uses an active fixation lead attached to a resterilized permanent pacemaker generator taped to the patient’s skin. It functions as an external device but allows early ambulation and, critically during the pandemic, discharge home.

To reduce his exposure to COVID-19 in the hospital setting, the man was discharged home rather than being transferred to the medical ward for continued monitoring with traditional temporary pacing.

Two weeks after placement of his temporary permanent pacemaker, his heart block had completely resolved and the device was removed.

The timeline reflects the typical recovery pattern in Lyme carditis treated with antibiotics – heart block resolving within days to weeks as spirochete-induced inflammation subsides.

Why This Matters

The temporary permanent pacemaker approach addresses several challenges in Lyme carditis management:

Avoids permanent pacemaker placement: Approximately 17.9% of Lyme carditis patients ultimately receive permanent pacemakers according to literature reviews. Many of these could be avoided with patience and appropriate temporary support during antibiotic treatment. For a 31-year-old, avoiding permanent pacing means avoiding decades of device complications, generator replacements, and psychological burden.

Reduces hospital length of stay: Traditional temporary transvenous pacing requires continued hospitalization for monitoring. The TPPM allows discharge home in select patients, reducing nosocomial infection risk and healthcare costs.

Minimizes COVID-19 exposure: During the pandemic, prolonged hospitalization increased viral exposure risk. The ability to discharge patients home while maintaining cardiac pacing offered significant safety advantages.

Maintains quality of life: Early ambulation and home recovery improve patient comfort and psychological well-being compared to bed rest with traditional temporary pacing.

Patient Selection Considerations

The temporary permanent pacemaker approach isn’t appropriate for all Lyme carditis patients. Selection criteria likely include:

• Hemodynamically stable patients requiring pacing
• Reliable patients who will follow discharge instructions
• Access to appropriate monitoring and follow-up
• No complications requiring continued hospitalization
• Clinical trajectory suggesting antibiotic response

The authors emphasize this is “a safe and feasible strategy in select individuals” – not a universal approach but a valuable option for appropriate candidates.

The Broader Context

This case demonstrates the importance of clinical flexibility in Lyme carditis management. While guidelines provide frameworks, individual patient circumstances – including a global pandemic – may warrant creative solutions that maintain safety while optimizing outcomes.

The fundamental principle remains unchanged: avoid permanent pacemaker placement when possible by allowing time for antibiotic treatment to reverse the conduction abnormality. The temporary permanent pacemaker simply offers another tool to bridge that recovery period.

Clinical Perspective

In my practice, I’ve seen the devastating impact of unnecessary permanent pacemakers in young Lyme carditis patients. A 20-year-old with a permanent device faces 60+ years of generator replacements, lead complications, activity restrictions, and psychological burden – all potentially avoidable with appropriate temporary support during antibiotic treatment.

The temporary permanent pacemaker approach represents the kind of innovation we need in Lyme carditis management – maintaining patient safety while avoiding irreversible interventions for a reversible condition.

“Our case demonstrates that the use of a [temporary permanent pacemaker] for AV-dissociation secondary to [Lyme carditis] is a safe and feasible strategy in select individuals which can minimize patient morbidity, as well as hospital length of stay and overall health care costs.”

Frequently Asked Questions

What is a temporary permanent pacemaker?

A temporary permanent pacemaker uses an active fixation lead attached to a resterilized permanent pacemaker generator taped to the patient’s skin. It functions as an external temporary device but allows mobility and potentially early discharge.

How long does Lyme carditis heart block take to resolve?

Most cases resolve within days to weeks with antibiotic treatment. This patient’s heart block resolved completely within two weeks, which is typical for promptly treated Lyme carditis.

Do all Lyme carditis patients need pacemakers?

No. Most patients do not need permanent pacemakers. Temporary pacing may be needed during antibiotic treatment, but heart block typically resolves as the infection is treated, allowing pacemaker removal.

Can you go home with a temporary pacemaker for Lyme carditis?

With a temporary permanent pacemaker (TPPM), select stable patients may be discharged home. Traditional temporary transvenous pacemakers typically require continued hospitalization for monitoring.

Why avoid permanent pacemakers in young Lyme carditis patients?

Lyme carditis is reversible with antibiotics. A permanent pacemaker in a 20- or 30-year-old means decades of device complications, multiple generator replacements, psychological impact, and substantial healthcare costs – all potentially unnecessary for a condition that resolves with treatment.