Temporary Pacemaker for Lyme Carditis: Avoiding Permanent Implants

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 pacemakers.

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 provide an effective 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 experienced multiple syncope episodes — a warning sign of severe cardiac conduction disturbance. His history was classic for Lyme disease:

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

A temporary transvenous pacemaker (TTVP) was inserted via the right internal jugular vein on admission.

He was treated empirically with intravenous ceftriaxone — the recommended approach when
Lyme carditis is suspected, rather than waiting for test confirmation.

On day 5, Lyme carditis was confirmed by positive testing. Rather than continuing traditional temporary pacing with prolonged hospitalization, clinicians made a strategic decision.

The Temporary Permanent Pacemaker Strategy

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

This approach uses an active-fixation lead connected to a resterilized permanent pacemaker generator taped to the patient’s skin. Although technically external, the system allows patient mobility and potential early discharge.

To reduce exposure to COVID-19, the patient was discharged home rather than remaining hospitalized with traditional temporary pacing.

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

This recovery timeline reflects the typical pattern in
Lyme carditis treated with antibiotics, where heart block resolves as inflammation from Borrelia burgdorferi subsides.

Why This Matters for Lyme Carditis Patients

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

Avoids permanent pacemakers. About 17.9% of Lyme carditis patients receive permanent pacemakers according to published reviews. Many of these may be avoidable with temporary pacing while antibiotics resolve the infection.

Reduces hospital stays. Traditional temporary pacing requires inpatient monitoring. TPPM may allow discharge home in selected patients.

Improves safety during infectious outbreaks. During the COVID-19 pandemic, minimizing hospital exposure was particularly important.

Maintains quality of life. Patients can ambulate and recover at home instead of remaining confined to a hospital bed.

Patient Selection Considerations

This strategy is not appropriate for all Lyme carditis patients. Appropriate candidates likely include:

• Hemodynamically stable patients needing pacing
• Reliable patients able to follow discharge instructions
• Access to follow-up monitoring
• No other complications requiring hospitalization

The authors emphasize this is a safe approach in select individuals, not a universal strategy.

The Broader Context of Lyme Carditis Treatment

This case highlights the importance of flexibility in Lyme carditis management. While guidelines provide structure, individual patient circumstances may justify innovative solutions that maintain safety while improving outcomes.

The central principle remains unchanged: whenever possible,
avoid permanent pacemaker placement and allow time for antibiotic therapy to reverse the conduction abnormality.

Clinical Perspective

In my practice, I have seen the long-term impact of unnecessary permanent pacemakers in young Lyme carditis patients.

A 20-year-old receiving a permanent device may face decades of generator replacements, lead complications, and activity limitations — often for a condition that would have resolved with appropriate antibiotic treatment and temporary pacing support.

“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, hospital length of stay, and healthcare costs.”

Frequently Asked Questions

What is a temporary permanent pacemaker?

A temporary permanent pacemaker uses an active fixation lead attached to an externalized permanent pacemaker generator. It allows mobility and can sometimes permit early discharge.

How long does Lyme carditis heart block last?

Most cases resolve within days to weeks after antibiotic treatment begins.

Do Lyme carditis patients always need pacemakers?

No. Many patients only require temporary pacing while antibiotics treat the infection.

Why avoid permanent pacemakers in Lyme carditis?

Lyme carditis is reversible. Implanting a permanent pacemaker may expose young patients to decades of device-related complications.

Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.

Symptoms • Testing • Coinfections • Recovery • Pediatric • Prevention