Abstract
A 70-year-old man underwent dual-chamber pacemaker implantation for symptomatic tachycardia–bradycardia syndrome. The right ventricular (RV) lead was screwed into the RV high septum with a nondeflectable delivery catheter. Two months after implantation, the RV lead perforated through the left ventricular free wall (LVFW) and was identified via computed tomography. The patient underwent open chest surgery. The RV lead was extracted, and a new lead was reinserted at the RV apex after suturing the perforated wounds. Intraoperatively, the extracted lead perforated LVFW beside the first diagonal branch of the left anterior descending artery through the RV septum and the left intraventricular wall instead of the LV cavity. These findings support that the bloody pericardial effusion due to LV perforation in this case originated from RV venous blood but not LV arterial blood and resulted in cardiac perforation of the oozing type instead of the blowout type. The patient was discharged on day 15 post operation, and the patient’s situation has been uneventful for a year.
Learning objective
This is a rare case of delayed cardiac tamponade from left ventricular (LV) free wall perforation by a right ventricular (RV) septal lead involving both the RV septum and left intraventricular wall. Appropriate lead management and anatomical understanding are necessary to avoid such complications. If LV free wall perforation and cardiac tamponade are noted, an open surgical procedure for lead removal should be considered as the preferred therapeutic option.
Introduction
The incidence of cardiac perforation caused by the lead of a cardiac implantable electronic device (CIED) has a reported incidence of 0.1 %–5.2 % [ ]. It is a rare complication but is considered serious because it can result in cardiac tamponade or pacing failure. Usually, it occurs shortly after CIED implantation, but a few cases involving its occurrence in the subacute and late periods have been reported [ , ]. Currently, the right ventricular (RV) lead is more frequently screwed into ventricular septum, including the His bundle and left bundle branch at the CEID implantation due to the benefits for cardiac prognosis owing to pacing in the stimulus conduction system [ ]. Herein, we report a rare case of left ventricular (LV) free wall oozing perforation by the RV septal lead involving both the septum and left intraventricular wall.
Case report
A 70-year-old man was admitted to our hospital because of syncopal attack. Electrocardiography (ECG) performed at admission revealed a sinus pause of 7.2 s after the termination of paroxysmal atrial fibrillation (PAF). He was diagnosed with symptomatic tachycardia–bradycardia syndrome presenting PAF ( Fig. 1 A ) and underwent dual-chamber pacemaker implantation (PMI). A thin lumenless RV lead with a diameter of 1.37 mm (SelectSecure; Medtronic, Minneapolis, MN, USA) was inserted and carefully screwed into the RV high septum with a nondeflectable delivery catheter (C315His sheath; Medtronic). We confirmed the torque after screwing in the lead and the absence of excessive deflection of the lead. There were no abnormalities on X-ray imaging and no complications during admission (RV lead impedance, threshold and sensing were 684 Ω, 1.2 V, and > 10 mV intraoperatively and 551 Ω, 0.5 V, and 7.1 mV on day 7 post operation, respectively) ( Fig. 1 B). At the first visit, one month after the implantation, there were no symptoms, no abnormalities in device parameters, no changes in the lead position, and no findings of cardiomegaly on X-ray imaging ( Fig. 2 A ). However, 2 months after the implantation (day 60), the patient visited our hospital complaining of exertional shortness of breath, which had been occurring for approximately 2 weeks. The patient was in a steady hemodynamic state, and an examination was performed in advance. Chest X-ray imaging showed marked cardiomegaly in comparison with the findings on day 28 ( Fig. 2 B). Computed tomography and transthoracic echocardiography indicated RV septal lead perforation ( Fig. 2 C and D) and showed the tip of the RV lead exiting in the left thoracic cavity and passing through the septum and the LV free wall. RV lead data did not show any remarkable changes except for RV sensing (RV lead impedance, threshold, and sensing were 665 Ω, 0.25 V, and 2.6 mV respectively). As the patient’s symptoms worsened and an anticoagulant drug (edoxaban 60 mg) was administered, we chose open chest surgery for extraction of the penetrating lead following discussion among the members of the heart team. The patient underwent off-pump open chest surgery. The RV lead was extracted, and a new lead (CapsureFix Novus MRI; Medtronic) was transvenously reinserted at the RV apex after suturing the perforation wounds ( Fig. 3 A, B ). Intraoperatively, we noted that the extracted lead perforated the LV free wall beside the first diagonal branch of the left anterior descending artery (LAD) through the RV septum and left intraventricular wall instead of the LV cavity ( Fig. 3 A). These findings support that the bloody pericardial effusion due to LV perforation in this case originated from RV venous blood but not LV arterial blood and resulted in cardiac perforation of the oozing type instead of the blowout type. There was no critical lung damage even though part of the lead was in contact with the lung. The patient was discharged on day 15 post operation, and the patient’s situation has been uneventful for a year.
