Cardiac wall perforation is a recognized complication of pacemaker lead fixation. It is typically associated with deterioration of electrical parameters; however, this case demonstrates that perforation may occur despite normal parameters and apparently normal device function. In patients with recent cardiac electronic device implantation, persistent or pleuritic chest pain should raise suspicion of myocardial perforation. Transthoracic echocardiography may be diagnostic, and cardiac computed tomography provides definitive confirmation when uncertainty remains.
Clinical Presentation
A 70-year-old woman with a medical history significant only for mild chronic obstructive pulmonary disease was referred for permanent pacemaker implantation because of intermittent Mobitz type II atrioventricular block. A dual-chamber pacemaker was implanted using active-fixation atrial and ventricular leads.
Immediately after implantation, the patient developed acute pleuritic chest pain. A chest X-ray demonstrated a pneumothorax, which was treated with chest tube drainage. After radiographic resolution, the patient was discharged with mild residual discomfort. Transthoracic echocardiography performed before discharge did not reveal pericardial effusion.
In the days following discharge, the patient continued to experience pleuritic chest pain and progressive easy fatigability. She presented 3 times to her local emergency department, where symptoms were each managed conservatively with analgesics. Given that the pain was described as mild and considering the recent history of pneumothorax with reportedly negative chest X-rays, the patient was reassured and discharged on each occasion. She subsequently developed transient fever and gastrointestinal symptoms, which resolved spontaneously within approximately 1 week, further supporting the initial clinical assessment.
One month after implantation, the patient attended her first scheduled pacemaker follow-up visit. She reported persistent chest discomfort but denied syncope or overt heart failure symptoms. Pacemaker interrogation was performed, and pacing and sensing parameters were recorded ( Table 1 ). No immediate therapeutic action was taken.
Table 1
Pacemaker lead parameters right after implantation vs 1-month follow-up.
| Parameters | Right atrium | Right ventricle | ||
|---|---|---|---|---|
| Implant | Follow up | Implant | Follow up | |
| Impedance | 600 Ω | 583 Ω | 940 Ω | 562 Ω |
| Sensing | 1 mV | 3.5 mV | 13.8 mV | 14.3 mV |
| Threshold | 0.6 V–0.4 ms | 0.7 V–0.4 ms | 0.3 V–0.4 ms | 0.3 V–0.4 ms |
Values shown were carried during bipolar testing; unipolar mode was also verified and deemed normal.
Ω = ohms; mV = millivolts; ms = milliseconds.
Question 1
What do the pacemaker electrical parameters reported in Table 1 most appropriately indicate at this stage?
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The absence of clinically relevant complications related to the device
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Appropriate electrical function of the pacing system at the time of interrogation
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Structural integrity of the myocardium at the lead implantation site
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A low likelihood of future device-related complications
Two days later, the patient presented again to the emergency department because of new-onset palpitations, in addition to persistent pleuritic chest pain and fatigue. An electrocardiogram showed atrial fibrillation with a ventricular rate of 140 beats/min. Pharmacological cardioversion with intravenous amiodarone restored sinus rhythm.
Laboratory testing revealed marked leukocytosis (22,000 cells/µL), prompting further evaluation.
Transthoracic echocardiography demonstrated a diffuse pericardial effusion, with maximal thickness of 16 mm at the right ventricular apex. In the same region, the ventricular pacing lead appeared to extend beyond the expected right ventricular contour, projecting outward for approximately 12 mm ( Figure 1 ).
Echocardiography, off-axis view, enhancing the protruding ventricular lead piercing the right apex ( yellow circle ) for 12 mm in the context of a consequential pericardial effusion.
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