Rib Perforation From a Right Ventricular Pacemaker Lead

Abstract

A 50-year-old man was admitted to a community hospital for high fever. Seven years earlier, he had been in a motor vehicle accident and a cervical spine injury had resulted in quadriplegia and ventilator dependence. During that hospitalization, he was noted to have long sinus pauses that were thought to be vagally mediated, and a single-chamber pacemaker was implanted to hasten his recovery, with an active fixation pacing lead placed at the right ventricular apex ( Figure 1A through 1C). His bradycardia spells subsequently disappeared, and minimal pacing was needed.Because of spiking fevers, leukocytosis, and methicillinresistent Staphylococcus aureus growing from blood cultures; a chest x-ray ( Figure 1D) and a chest computed tomography scan ( Figure 2) were performed. Neither revealed any obvious source of infection, but his ventricular pacing lead had perforated through the right ventricular apex, with the lead tip now sitting in soft tissue just outside the rib cage near the seventh rib.Although it was not clear whether the pacemaker lead was infected in either its intravascular or extracardiac course, it was decided that the lead should be removed to avoid future mechanical complications at the least. The patient was referred for surgical pacemaker-system extraction. In the operating room, chest wall exploration revealed ventricular lead penetration through the seventh rib ( Figure 3A). Local granulation tissue and a short segment of the perforated rib were resected ( Figure 3B) and sent for culture. The lead was disconnected from the right pectoral pacemaker generator, and manual traction was used to free the lead from intravascular binding sites. The apical defect in the right ventricle was closed with a purse-string suture. There was no evidence

Subacute Presentation of Right Ventricular Perforation after Pacemaker Implantation

“…[3][4][5] Lelorier noted that despite every precaution taken to avoid this complication, most operators, regard- less of skill and experience, will encounter a perforation.…”

Delayed Cardiac Perforation by Defibrillator Lead Placed in the Right Ventricular Outflow Tract Resulting in Massive Pericardial Effusion

“…Significantly, a majority of such perforations were “subclinical,” in the sense the CT scans were not ordered for suspected device‐related complications and the lead parameters were satisfactory. On the other hand, cardiac perforation by transvenous leads can result in pericardial effusion or tamponade; deterioration in lead parameters; failure of or inappropriate device therapy; (hemo‐)pneumothorax; chest pain; muscle twitching; perforation of the lungs, diaphragm or chest wall; and even death 2–12 …”

Delayed Right Ventricular Perforation by a Transvenous Active Fixation Implantable Cardioverter-Defibrillator Lead

“…In the cases reported, late cardiac perforation has been confirmed when necessary by right ventriculography 2 or, more often, by chest computed tomography. [3][4][5][6] As far as we know, echocardiography has not been reported as a method to confirm the cause of cardiac tamponade in these cases. In our case, echocardiographic images clearly showed the tip of the lead going in and out through the right ventricular wall into the pericardial space, confirming the diagnosis of delayed right ventricular perforation by the ICD lead.…”