Key Clinical Message
Lead perforation is a life‐threatening rare complication of pacemaker or defibrillator lead implantation. Clinical examination, electrocardiogram, device interrogation, echocardiography, chest x‐ray, and chest computed tomography scan can help in the diagnosis. Clinicians should be aware because early diagnosis and treatment are the cornerstones for achieving a better outcome.
Keywords: cardiac tamponade, devices complications, lead perforation, pacemaker complications
An 83‐year‐old male patient presented to the emergency department with a 4 days history of fever 38°C and dyspnea. His medical history included paroxysmal AF, hypertension, surgically repaired abdominal aortic aneurysm, and a recent (1 month ago) dual‐chamber pacemaker implantation because of complete atrioventricular block. At the emergency room, the patient was asymptomatic and hemodynamically stable. The 12‐lead electrocardiogram showed sinus rhythm with pacemaker rhythm at 70 pulses/min. Chest x‐ray revealed a small right‐sided pleural effusion without specific abnormal findings in the position of pacemaker leads. Cardiac ultrasonography showed circular pericardial effusion (1.4 cm) without echocardiographic findings of cardiac tamponade. Device interrogation revealed loss of capture of the atrial lead while impedance and sensing were within normal range. Chest computed tomography revealed pericardial effusion with attenuation close to that of water without other pathological findings. At the day 3 of hospitalization, the patient developed cardiac tamponade and he was transferred at the operating room. The atrial pacemaker lead was found to perforate the superior vena cava, the external wall of the right ventricle, and subsequently crossed through the wall of the right atrium (Figure 1). The cardiothoracic surgeons decided a conservative treatment with pericardial sac washing with water saline without lead extraction because the perforation was characterized as delayed (more than 1 month after implantation)1 and the extraction was considered high‐risk. The device was programmed in VVD mode. At 3 months follow‐up, the patient was asymptomatic while repeated echocardiography exams did not reveal pericardial effusion.
Figure 1.
Lead perforation–A life‐threatening complication of pacemaker implantation
CONFLICT OF INTEREST
None declared.
AUTHORSHIP
GB, VP, MT, AS, EK, KT, A‐MK, AS, IL, CC, AS: involved in management of the patient, major revision, final approval. PK: involved in major revision, final approval.
Bazoukis G, Panagiotakopoulos V, Tsamatsoulis M, et al. A rare complication of pacemaker implantation. Clin Case Rep. 2018;6:1891–1892. 10.1002/ccr3.1715
REFERENCE
- 1. Hirschl DA, Jain VR, Spindola‐Franco H, et al. Prevalence and characterization of asymptomatic pacemaker and icd lead perforation on ct. Pacing Clin Electrophysiol. 2007;30:28‐32. [DOI] [PubMed] [Google Scholar]