Tale of a Wandering Lead: Late Atrial Lead Perforation into Right Lung following Pacemaker Implantation

Abstract

Cardiac perforation by a pacemaker lead is a rare complication of pacemaker implantation. Presentation can vary from chest pain and shortness of breath to the patient being completely asymptomatic. Diagnosis is usually made by high-resolution computed tomography (HRCT) scan of the chest. Electrocardiograph (EKG) usually shows the absence of a paced rhythm, but it doesn't provide a definitive diagnosis. We describe a case of late cardiac perforation by an atrial pacemaker lead with no signs or symptoms of pericardial tamponade.

Case report: A rare complication after the implantation of a cardiac implantable electronic device: Contralateral pneumothorax with pneumopericardium and pneumomediastinum

“…In concerning cases, fluoroscopy, chest CT with three-dimensional reconstruction, and echocardiography assist in diagnosing lead perforation ( 13 , 31 ); however, they are not as sensitive for tiny perforation ( 15 , 19 , 23 , 32 ). ECG-gated high-resolution CT (HRCT) remains the diagnostic gold standard although the perforation may be over-diagnosed ( 19 , 25 , 27 ). To reduce imaging distortions caused by heart motion, prospective ECG triggering and retrospective ECG gating methods are introduced ( 33 ).…”

“…Complications from pacemaker implantation are 30% more likely in females than in males (3). The incidence of both venipuncture related injury and cardiac perforation is higher in patients with bullous emphysema, chronic obstructive pulmonary disease (COPD), congenital defects such as persistent left superior vena cava, age >80 years, Caucasian ethnicity, steroid treatment within 7 days, anticoagulant and antiplatelet therapy, urgent surgery, low BMI (<18.5), or agitation (1,8,15,(18)(19)(20). Prior procedures, operation (such as sternotomies), trauma, or irradiation therapy in the affected area, clavicle/chest deformity, and previous fractures, are all significant risk factors.…”

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

“…Women have a 30% higher risk than men of encountering any complication from pacemaker therapy, mainly due to a 50% higher risk of pneumothorax (2.2%) and cardiac perforation (1.1%) [2]. Shared risk factors for pneumothorax and cardiac perforation besides female gender are BMI<20, age>80 years, chronic obstructive pulmonary disease (COPD), bullous emphysema, corticosteroid treatment, anticoagulation, platelet therapy, emergency procedure, restless and uncooperative patient, and inexperienced operator [2,5,[8][9][10][11][12].…”

“…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].…”

“…Pneumothorax occurs in 1%-2% of all pacemaker operations, due to needle injury of the pleura typically when attempting to gain access to the subclavian vein [1][2][3][4][5]. Perforation of a pacemaker electrode through the cardiac free wall occurs in 1%-2% of pacemaker implantations, whereas electrode perforation of the pleura resulting in pneumothorax is very rare [5][6][7][8][9] (estimated less than 0.0001% of all pacemaker implantations).…”