Recurrent Pericardial Chest Pain: A Case of Late Right Ventricular Perforation After Implantation of a Transvenous Active‐Fixation ICD Lead

Abstract

A 36-year-old woman with a history of recurrent syncopal episodes presumably due to ventricular tachyarrhythmia in mitral valve prolapse underwent implantation of a transvenous ICD system. During a 23-month follow-up, she developed recurrent pericardial chest pain with pericardial friction rub. The first episode of chest pain occurred without any detectable change in pacing or sensing parameters. The second episode was associated with an increase in pacing threshold and drop in intracardiac signal amplitude. Right ventricular perforation was suspected fluoroscopically and confirmed by right ventriculography. This case report emphasizes the key steps in the diagnosis of this rare complication of an ICD implantation.

Perforation of the right ventricular free wall by an ICD lead in a patient with isolated noncompaction of the ventricular myocardium

“…The ICD lead perforating the right ventricular apex upon surgery. lead has also been reported previously [4]. On the other hand, as compared to candidates for pacemaker implantation, candidates for ICD implantation may have higher incidence of myocardial disease such as arrhythmogenic right ventricular cardiomyopathy, dilated cardiomyopathy and myocardial infarction that cause the right ventricular wall to become thinner and prone to perforation.…”

“…The implantable cardioverter defibrillator (ICD) lead is thicker and stiffer than usual pacemaker leads and thus, more likely to cause perforation [3,4]. We describe a case of perforation of the right ventricular free wall by an ICD lead in a patient with isolated noncompaction of the ventricular myocardium.…”

Life-threatening perforation of a defibrillation lead

“…4 Also, lead perforation may occur more than one year after implantation. 5 Echocardiography and X-ray are often sufficient to determine the diagnosis of lead perforation. Major risk factors for cardiac perforation are female gender, age, body mass index <20, anticoagulation therapy, use of steroids and leads with an extendable fixation helix.…”

“…4 Also, lead perforation may occur more than one year after implantation. 5 Echocardiography and X-ray are often sufficient to determine the diagnosis of lead perforation. Major…”

Radiology of cardiac devices and their complications

“…Perforation is usually recognized during placement but may present later after implantation as either an asymptomatic subacute perforation or as a late perforation. [13][14][15][16] Pacemaker insertion generally results in a lower rate of perforation than ICD insertion with many studies citing ,1% perforation rate for pacemakers and up to 5% for ICDs. 17,18 This difference has been attributed to the ICD lead's larger diameter than that of a pacemaker lead.…”