Figure 2.

Right ventricular perforation by the ICD lead, visualized by transthoracic echocardiography, before and after lead repositioning. The upper part shows the modified 4-chamber view (the specific inclination of the tomographic plane to attain this plane is schematically shown in the diagram at the bottom left, where the dashed-line-delimited plane indicates the standard 4-chamber view plane orientation), that shows the tip of the wire (due to its minuscule structure, actually the helix) penetrating 2–3 mm into the fluid-filled pericardial space (on the upper left side, a photo of the distal part of the lead is reported, with its characteristics indicated: helix, the fixating screw (long arrow), tip electrode (short arrow), ring electrode (arrow head), and the distal defibrillator electrode (bracket)). The lower part shows the same echocardiographic view after unscrewing the helix, along with minimal lead retraction: no more protrusion of the lead into the pericardial space is visible; in addition, some hypereflective zones along the lead are visible by echo, that should correspond to the electrodes (arrow heads) and coils (arrows). RV = right ventricle; Per E = pericardial effusion.