Right ventricular lead perforation with iatrogenic injury to an intercostal artery causing haemothorax after pacemaker implant

Abstract

A woman in her 80s experienced a life-threatening complication of pacemaker implant consisting of subacute right ventricular lead perforation causing iatrogenic injury to an intercostal artery, resulting in a large haemothorax. A CT scan confirmed active bleeding from the fourth intercostal artery. The patient underwent cardiothoracic surgery via a median sternotomy approach, during which the source of the bleeding was sealed, a new epicardial lead was positioned, and the original lead was extracted. This case emphasises the potentially severe consequences of pacemaker lead perforation and secondary injury to adjacent structures. It underscores the importance of early recognition and timely intervention, preferably in a tertiary specialist unit equipped for cardiothoracic surgery and confirms the value of pacemaker interrogation and CT scans for diagnosis.

Background

Pacemaker therapy is an effective treatment for bradyarrhythmias, most commonly indicated for sinus node dysfunction or high-grade atrioventricular block.¹ With an ageing population and longer life expectancy, pacemaker use is increasing, with approximately one million people worldwide undergoing pacemaker implantation each year.^{2 3}

While generally safe, pacemaker therapy can have complications, most of which occur within the first 30 days after implantation.⁴ Complications include bleeding, infection, lead dislodgement, pneumothorax, air embolism, lead perforation and thrombosis, on rare occasions, resulting in death.⁴ Lead perforation is a rare but serious adverse event, occurring in approximately 0.3%–0.7% of implants.¹ It can result in acute pericarditis, pericardial effusion or tamponade, constrictive pericarditis, pleural effusion, haemothorax, pneumothorax, lung perforation, diaphragmatic stimulation or be without clinical manifestation.¹ Patients with lead perforation are at increased risk of other major complications, in-hospital mortality, and, potentially, infection related to early reintervention.⁵

Case presentation

A woman in her early 80s with a history of atrial fibrillation and temporarily interrupted apixaban treatment underwent dual chamber pacemaker implantation with active fixation leads for bradycardia-tachycardia syndrome at a regional hospital. Apixaban was reinitiated following the implant. Two days after the procedure, the patient presented to the emergency department with chest pain that had started the night following the implantation. On arrival at 20:20 hours, the patient was in substantial pain, displayed rapid atrial fibrillation on ECG and had a blood pressure of 197/109 mm Hg. Physical examination revealed normal temperature and decreased breath sounds on the left side. The pacemaker site showed no signs of infection or haematoma. Initial evaluation revealed haemoglobin level of 130 g/L, C reactive protein level of 9 mg/L and troponin T at 33 ng/L.

Investigations

A contrast-enhanced CT scan of the thorax identified a large left-side haemothorax and right ventricular lead perforation. While in the radiology department, the patient’s systolic blood pressure significantly declined to 75 mm Hg. The patient exhibited symptoms of peripheral vasoconstriction–pale skin and cold extremities–but remained conscious. The patient was transferred to the intensive care unit and stabilised with intravenous fluids. Her haemoglobin level declined to 76 g/L. Intervention included administering four units of fresh frozen plasma and four units of packed red blood cells. Transthoracic echocardiography did not reveal significant pericardial effusion. A left-sided thoracotomy tube was inserted, draining 1.5 L of dark blood. Because of the urgency of the situation, the patient was transferred via helicopter to our tertiary specialist unit for cardiothoracic surgery, receiving three additional units of red blood cells during the transfer.

On arrival at our unit, the patients’ haemoglobin level was 103 g/L. Pacemaker interrogation revealed low R wave amplitude and low impedance of the right ventricular lead. A subsequent ECG-triggered CT scan revealed a massive accumulation of blood in the left pleura, displacing the mediastinum to the right. Active extravasation was observed from the fourth left intercostal artery at the bone-cartilage junction. The tip of the right ventricular lead was located near the pericardium and directed towards the site of extravasation (figure 1). However, the volume of blood within the pericardium was relatively small.

Figure 1.

Multiplanar reformations of arterial phase CT imaging of the thorax in sagittal (A), axial (B), and coronal (C) views, showing an extensive haemothorax. Blue arrow: extravasation of contrast medium from the intercostal artery (the artery itself is not visible). Orange arrow: the perforating ventricular electrode pointing towards the intercostal artery. Green arrow: thoracic drainage.The asterisk symbol in Figure 1 denotes the presence of a "Very large hemothorax" within the illustration for reference and emphasis.

Differential diagnosis

The symptoms and clinical findings in this case suggest several possible diagnoses. Initially, the patient’s chest pain and slightly elevated troponin level raised the possibility of a myocardial infarction or pulmonary embolism. However, considering that the pain onset was subsequent to pacemaker implantation, myocardial infarction was deemed unlikely, prompting a contrast-enhanced CT scan, which ruled out pulmonary embolism. Given the decreased left-side breath sounds, pneumothorax was also a consideration, but the CT scan disclosed a significant left-sided haemothorax with no evidence of pneumothorax. This finding was confirmed by subsequent blood drainage. While haemothorax can be a consequence of vessel injury during venous access in the implant procedure, the CT scan in this instance pointed to active bleeding from an intercostal artery as the most plausible source.

The presence of chest pain following pacemaker implantation, CT evidence of right ventricular lead perforation and pacemaker interrogation showing low R wave amplitude and lead impedance strongly suggested lead perforation. This diagnosis was consistent with the patient’s clinical presentation and further supported by radiological evidence. Although right ventricular lead perforation carries a risk for pericardial effusion or cardiac tamponade, neither the transthoracic echocardiogram nor the CT scan revealed significant pericardial effusion. Therefore, while tamponade remained a diagnostic consideration, the prevailing evidence did not strongly support it.

Treatment

Following the administration of thrombocytes, coagulation factors II and IX, and fibrinogen, the patient underwent cardiothoracic surgery via median sternotomy. On opening the pericardial sac, pressurised blood was discovered and promptly evacuated. The left pleura was then opened, revealing a large haemothorax. Multiple litres of clots and an additional 1.7 L of blood were suctioned from the pleura. The source of bleeding was identified in the lateral intercostal space and was sealed using sutures, then reinforced with a topical fibrin sealant patch. The right ventricular lead was found to have perforated and extended through the pericardial wall. A new epicardial right ventricular lead was subsequently placed and tunnelled subcutaneously to the device pocket. The transvenous right ventricular lead was then percutaneously removed, and the right ventricle was repaired. The thoracotomy tube was replaced, and another tube was inserted into the mediastinum. During the surgery, the patient received transfusions of seven units of erythrocytes and seven units of plasma.

Outcome and follow-up

Postoperative, the patient’s haemoglobin levels stabilised, and no additional blood transfusions were necessary. Three days after the surgery, the patient was transferred to the regional hospital and discharged to home 4 days later. The patient was readmitted once for a left pleural effusion that required drainage. Three months postsurgery, the patient underwent electrical cardioversion and made a full recovery. At the most recent follow-up in May of 2023, more than 2 years after pacemaker implantation, the patient was found to be in good health, leading an active lifestyle and had not experienced further complications.

Discussion

This report describes a case of lead perforation following pacemaker implantation, leading to iatrogenic intercostal artery perforation, a large haemothorax and life-threatening haemorrhagic shock. Although rare, lead perforation, represents a serious and potentially life-threatening complication of pacemaker implantation.¹ Perforation can occur during the procedure, hours to months later, or, rarely, years later.^{1 6} Thoracic symptoms within days of pacemaker implantation should prompt immediate consideration of lead-related complications as a primary differential diagnosis, highlighting the need for vigilance in the postimplantation period.¹

In our case, pacemaker interrogation, a basic diagnostic approach, was not performed at the regional hospital due to limited capabilities outside of regular office hours when the patient presented acutely. This omission highlights the need for comprehensive diagnostic availability in emergency settings. CT scans are essential in confirming lead perforation, localising the precise site of the perforating lead tip and identifying secondary injuries, such as bleeding from an intercostal artery, as observed in our patient. Transthoracic echocardiography is a sensitive tool for detecting pericardial effusion.⁷ These approaches ensure early diagnosis and appropriate management, crucial for patient outcomes.

In this case, the lead not only perforated the myocardium of the right ventricle but also penetrated the pericardium, extending into the pleura to pierce an intercostal artery, resulting in a large haemothorax. Hence, the consequences of perforation were magnified by secondary injury to surrounding structures, exacerbating an already serious clinical scenario. Lead perforation with pleural space penetration and direct injury to the left lung or intercostal artery has been reported with both atrial and ventricular leads.^8–10 Saunderson et al described a case similar to ours, but with injury to an intercostal artery first identified during thoracic surgery when the patient remained hypotensive after the right ventricle was repaired.¹¹ Forleo et al reported a case of massive acute haemothorax resulting from intercostal artery laceration subsequent to lead perforation 10 months postimplantation.¹² There have also been case reports of right haemopneumothorax due to right atrial lead perforation.^{13 14} Despite these documented occurrences, this complication remains relatively unknown among clinicians.¹¹

The management of lead perforation is generally surgical, particularly when associated with conditions such as tamponade or haemothorax.⁷ The surgical procedure typically involves lead extraction and repair of the perforation site. However, the choice of surgical management and approach is influenced by factors including the patient’s overall condition, the location and extent of the perforation, and the presence of associated complications.⁷ In this case, a median sternotomy approach was chosen for its effective, comprehensive access and direct visualisation, allowing for more complex surgical repair. Other less invasive approaches, such as the subxiphoid approach or thoracotomy, offer limited access. Lead perforation should be managed in a high-volume tertiary specialist unit equipped for cardiothoracic surgery.

The experience of the operator and the volume of the implanting centre plays significant roles in minimising the incidence of lead perforations and other complications. Notably, lead perforations occur less frequently in high-volume centres (defined as those performing over 400 implants per year) due to greater procedural expertise.¹⁵ The implantation technique, including the depth of lead screw-in, angle of implantation and applied force, is critical factors. The use of active fixation leads, as in this case, has been associated with a higher risk of perforation compared with passive fixation leads.¹⁶ Apical placement of the right ventricular lead is also a risk factor for perforation.¹⁶ Despite the operator’s experience in our case, the medium-volume setting of the implanting centre may have influenced the risk profile.

Our patient’s advanced age, female gender and possibly unique anatomical characteristics, such as a thinner myocardium or abnormal heart and vessel positioning exacerbated by age-related changes, significantly contributed to the risk of this complication. The risk of perforation also increases with steroid use and low body mass index.¹⁶

As the utilisation of pacemakers and implantable cardiac defibrillators increases, particularly among the ageing population, the incidence of complications may increase correspondingly.^{2 3} This case report of a rare and severe complication following pacemaker implantation serves as a potent reminder of the need for heightened vigilance regarding lead perforation and secondary injuries. Pacemaker interrogation, prompt imaging and effective management are vital in addressing the adverse consequences of these procedures and are crucial for successful outcomes. The case underscores the importance of experienced operators with skilled technique, appropriate technology selection and comprehensive preprocedural planning. These measures are essential to minimise risks, especially in patients with identifiable risk factors, thereby enhancing the safety and effectiveness of pacemaker therapy.

Patient’s perspective.

Written by the patient two years after the pacemaker implant, translated by the authors of the case report.

On a Tuesday in 2021, I underwent surgery to have a pacemaker implanted. The procedure went as expected, and I was sent home on the same day. Later that evening, I experienced severe stabbing pains in the chest on multiple occasions. I contacted the medical department the next day to inquire about my pain. I was reassured by the nurse that everything was probably normal, but the pain persisted.

Two days later, the situation became critical because of the pain, prompting a call to the ambulance. The ambulance crew administered pain medication and transported me to the hospital, where I felt extremely ill and vomited. I underwent an X-ray and several other examinations, and tubes were inserted into my body. My memory of what happened next is blurry, but I do recall the hospital staff rushing me through the corridor while pulling a defibrillator off the wall.

At 03:30 AM, I informed my relatives that I needed to be transported by air ambulance to a university hospital. The helicopter ride was distressing, as it was cramped, noisy, and I felt very unwell. I distinctly remember landing and being greeted by the biting cold. Post-surgery, I felt nauseated and extremely weak, but I was under careful monitoring by the medical staff. By Saturday, I was able to take a few short steps to the toilet with the aid of a walker. I continued taking short walks on Sunday, and by Monday, I was considered strong enough to be transported back to my home hospital via ambulance bus. However, I was unable to board the bus myself and required assistance from the staff. The journey was gruelling because of my weakened state and the requirement to sit upright for such an extended period. I arrived utterly drained, feeling even worse than I had felt the previous day.

Being hospitalized during the pandemic was particularly challenging. Visitor restrictions meant my relatives could not come to see me, and hospital staff only entered my room briefly for medication administration, examinations, and at meal times. I also developed fluid in my pleural cavity, a complication that necessitated two drainage procedures.

Today, I am feeling much better and have returned to my normal routine, which involves being active and social.

Learning points.

• Vigilance for complications is essential in the initial days following pacemaker implantation.

• Pacemaker interrogation and CT scans are critical for diagnosing lead perforation.

• CT scans are instrumental in diagnosing secondary injuries, thus guiding appropriate intervention.

• Lead perforation should be managed in high-volume tertiary specialist units equipped for cardiothoracic surgery.

• Operator experience plays a significant role in impacting the risk and management of complications.

Ethics statements

Patient consent for publication

Consent obtained directly from patient(s).