“…The tip may be on the anteroseptal or inferoseptal junction, which are anatomic recesses located even more leftward than the true ventricular septum owing to the crescent shape of the RV. Lead positioning at these leftward locations carries an increased risk of perforation through the thin free wall of the RV, just as was seen in this case (Figure 1B; asterisk denotes the anteroseptal junction).Figure 1 A: Computed tomography image from Figure 2 in Iribarne and colleagues 1 , with added arrow showing lead trajectory and dotted line showing left ventricular endocardial border. B: Cross-sectional representation of the right ventricle (RV) and left ventricle (LV) on a traditional left anterior oblique view, with the asterisk denoting the anteroseptal junction.…”
mentioning
confidence: 60%
“…We read with great interest the article by Iribarne and colleagues 1 which describes a case of a pacemaker lead perforation. There are 2 issues that we would like to highlight, which we felt are vital for your readership.…”
mentioning
confidence: 99%
“…Mechanism of perforation: The authors surmise that despite the lead’s being placed on the true septum, perforation occurred through the interventricular septum, across the left ventricle (LV) chamber, through the LV free wall, and finally through the parietal pericardium and into the pleural space. In reality, however, the published computed tomography (CT) images show that the lead had instead perforated through the right ventricle (RV) free wall that is close to the septum (anteroseptal junction) and not through the interventricular septum (Figure 1A: CT image is taken from Iribarne and colleagues 1 Figure 2, with added arrow showing lead trajectory and dotted line showing LV endocardial border). It is critical for every implanting physician to be aware that a pacemaker lead tip pointing leftward on the left anterior oblique view does not indicate with certainty that the tip is on the ventricular septum.…”
“…The tip may be on the anteroseptal or inferoseptal junction, which are anatomic recesses located even more leftward than the true ventricular septum owing to the crescent shape of the RV. Lead positioning at these leftward locations carries an increased risk of perforation through the thin free wall of the RV, just as was seen in this case (Figure 1B; asterisk denotes the anteroseptal junction).Figure 1 A: Computed tomography image from Figure 2 in Iribarne and colleagues 1 , with added arrow showing lead trajectory and dotted line showing left ventricular endocardial border. B: Cross-sectional representation of the right ventricle (RV) and left ventricle (LV) on a traditional left anterior oblique view, with the asterisk denoting the anteroseptal junction.…”
mentioning
confidence: 60%
“…We read with great interest the article by Iribarne and colleagues 1 which describes a case of a pacemaker lead perforation. There are 2 issues that we would like to highlight, which we felt are vital for your readership.…”
mentioning
confidence: 99%
“…Mechanism of perforation: The authors surmise that despite the lead’s being placed on the true septum, perforation occurred through the interventricular septum, across the left ventricle (LV) chamber, through the LV free wall, and finally through the parietal pericardium and into the pleural space. In reality, however, the published computed tomography (CT) images show that the lead had instead perforated through the right ventricle (RV) free wall that is close to the septum (anteroseptal junction) and not through the interventricular septum (Figure 1A: CT image is taken from Iribarne and colleagues 1 Figure 2, with added arrow showing lead trajectory and dotted line showing LV endocardial border). It is critical for every implanting physician to be aware that a pacemaker lead tip pointing leftward on the left anterior oblique view does not indicate with certainty that the tip is on the ventricular septum.…”
“…5,23 Therefore, this appears to be the preferred place of implantation. 17,24,25 The typical history of patients with delayed perforation includes breath-dependent thoracic pain. Usually, the pain has a sudden onset at the time of lead perforation, which can be associated with symptomatic phrenic nerve stimulation in a larger proportion of patients (30% in our study), stimulation of the chest wall, or loss of capture with corresponding symptoms.…”
Section: Discussionmentioning
confidence: 99%
“…Fixation of RV leads at the interventricular septum seems to be associated with a significantly lower perforation risk due to the thicker myocardium 5,23 . Therefore, this appears to be the preferred place of implantation 17,24,25 …”
Introduction: Cardiac perforation is a rare complication of cardiac implantable electronic device (CIED) implantation. Transvenous revision of perforated leads is associated with the risk of cardiac tamponade and death. Little is known about periprocedural complications and outcome of these patients. Methods and results: All patients referred to our department with evidence or suspicion of cardiac perforation following CIED implantation underwent chest X-ray, transthoracic echocardiography, device interrogation, and, if necessary, a cardiac computed tomography (CT)-scan to diagnose lead perforation and associated complications. Transvenous lead revision (TLR) was performed in all patients with evidence of lead perforation. Patient characteristics, procedural complications, and outcome were recorded and analyzed. Fifty-six patients (75 ± 10 years, 43% male) were diagnosed with cardiac perforation, 34 patients (61%) early within 30 days post-implantation, and 22 patients (39%) thereafter. The most frequent perforation site was the right ventricular (RV) apex (75%), followed by the RV free wall (16%) and the right atrial appendage (9%). A total of 16 patients (29%) presented with severe complications; 12 patients (21%) with pericardial effusion treated by pericardiocentesis before lead revision and four patients (7%) with hematothorax requiring drainage. Late perforations showed significantly more frequent cardiac tamponades (P = .041). TLR was performed without further complications in 54 patients (96%). None of the patients required surgical treatment or experienced in-hospital death. Conclusions: Cardiac perforation following CIED implantation is associated with severe complications in nearly one-third of the cases. Transvenous revision of the perforated lead can safely be performed with a very low complication rate. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.
Late‐onset migration of pacing leads in the left hemithorax is a rare but potentially life‐threatening complication. Radiological examinations are required to detect any involvement of either left ventricle or lung parenchyma, prompting immediate surgical extraction in this setting. Identification of high‐risk patients is mandatory to prevent this complex iatrogenic complication.
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