Mechanism and Management of Pacing Lead Related Cardiac Perforation

Bilateral Pneumothorax Complicating Pacemaker Implantation, due to Puncture of the Left Subclavian Vein and Electrode Perforation of the Right Atrium

“…If the defect caused by perforation of the cardiac wall is small and plugged immediately due to cardiomyocyte contraction, then a pericardial effusion is avoided and the pneumothorax can be stabilized. A larger cardiac perforation can lead to pericarditis, pericardial effusion, tamponade, hemodynamic instability [14] and even death; pleuritis, chest pain, dyspnea, hypotension, and syncope [12,[15][16][17][18], abnormal pacemaker function (primarily a high threshold or loss of capture) [9, 11-12, 14-17, 19] and extracardiac pacing (diaphragmatic, pectoralis or intercostal muscle stimulation [14][15]19] and inappropriate shock [17]. Pneumopericardium and pneumothorax and pleural effusion are very rare complications [3, 6-9, 15, 17].…”

“…Perforation, with the lead or the helix outside the cardiac silhouette, can be diagnosed by means of fluoroscopy, chest radiography, and echocardiography [14,19], but these methods are not reliable for evaluating less severe lead perforation [8-9, 17, 20]. The diagnostic gold standard is ECG-gated highresolution computed tomography (HRCT) [9], which has optimal demarcation of the interface between the myocardium, blood, and fat [12,15,[17][18][19][20], although star artifacts from the pacemaker wire sometimes make it difficult to precisely identify the lead tip [8-9, 17, 19-20], and there is a risk of over-diagnosing perforation [16]. Apart from aiding in making the diagnosis HRCT also helps in planning lead retrieval as it gives a good assessment of the orientation of vital structures around the displaced lead [9,16].…”

“…Leadless pacemakers seem to be associated with a slightly higher perforation risk. Implantable cardioverter-defibrillator (ICD) leads have a larger diameter and a higher rate of perforation, whereas cardiac resynchronization therapy defibrillator (CRTD)-implantation is associated with the highest risk of perforation [3,[6][7][8][11][12][14][15][16][17].…”

“…Protective factors against perforation are hypertrophy, elevated high ventricular systolic pressure >35 mmHg, previous cardiac surgery, and BMI >30 [12,15].…”

“…Clinically relevant and symptomatic perforation of the cardiac wall occurs mostly within one month after implantation and in 0.3%-1.2% of all pacemaker procedures [6,[11][12]15]. Surprisingly, pericardial effusion was seen in 10% when newly implanted patients underwent a systematic echocardiographic evaluation, but it resolved spontaneously and rarely required therapy although most cases were probably caused by perforation of an implanted lead [11].…”