An 82-year-old woman underwent routine pacemaker implantation for paroxysmal atrioventricular block. The operator did not encounter any difficulties at the time of lead placement. At a predischarge check three days later, electrical signals and thresholds were excellent and similar to those at implant. The chest X-ray showed a good lead position in the right ventricular apex. During a routine one-month post-implant visit, the patient pointed out that she felt, two weeks after discharge, a violent left-thoracic pain. The pain started while the patient was lifting a heavy object and ended five days later. Pacing could not to be achieved and the electrograms were small. Fluoroscopy suggested perforation. There was no pericardial effusion on echocardiography. Ventricular perforation was confirmed by computed tomography scan ( Fig. 1 ). The tip of the lead (5076 Medtronic Inc., Minneapolis, MN, USA) was found in the subcutaneous tissues. Because the subsequent attempt to remove the lead could induce an acute cardiac tamponade, the procedure was performed in an operating theatre with a suitable emergency backup, that is, immediate availability of echocardiography, equipment for pericardiocentesis and a thoracic surgeon on stand by.
