Subacute right ventricular pacemaker lead perforation: evaluation by echocardiography and cardiac CT
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KeywordsChronic Obstructive Pulmonary Disease Right Ventricle Pericardial Effusion Cardiac Compute Tomography Pacemaker Implantation
Four days later, however, the patient was readmitted because of sharp chest pain, unrelated to physical activity or posture. Pacemaker data showed a marked switch from bipolar to unipolar lead pacing and malcapture of the RV lead at maximal pacemaker output. Chest radiography revealed an altered RV lead position (Fig. 1c, d). Echocardiography suggested a perforation of the RV lead through the RV apex but without pericardial effusion (Fig. 1e and online video). This raised doubt as to whether the lead tip lay in the pericardial space. Ultimately, thoracic computed tomography (CT) showed that the lead went through the myocardium (Fig. 1f, g). The patient was subsequently transferred to a specialized pacing lead extraction center with surgical backup, where the RV lead was repositioned uneventfully.
Acute complications (<24 h) after pacemaker implantation occur in 3–7% of patients, of which ~1% is due to myocardial perforation (MP) . In the subacute phase (1–30 days), MP may also occur, though less frequently, with an incidence of 0.03–0.4% of treated patients/year [2, 3].
Several predictors for development of MP are reported: old age (>80 years), female sex, RV apical lead positioning, and steroid use, while active fixation has been matter of debate [2, 3]. In our female patient, the RV lead was positioned in the RV apex. Although she was not over 80 years, she had nearly reached that age. In retrospect, the RV lead could have been positioned more septally.
MP has a wide variation in clinical presentation, ranging from clinically occult cases to cardiac arrest secondary to pericardial tamponade. Chest pain is the most frequently reported symptom .
Although routine chest radiography may be useful for evaluation of lead dislodgement, further imaging investigation is indicated if MP is suspected. Echocardiography can be useful in revealing presence of the RV lead in the pericardial space with or without pericardial effusion, but determining the exact lead tip position is difficult. CT, however, is superior in revealing lead tip position and in detecting MP (accuracy 92.9%, sensitivity 100%, and specificity 85.7%; echocardiography: 62.7%, 41.2%, and 84.2%, respectively) .
RP.J. Boxma: drafting article; M.G.M. Kolff-Kamphuis: critical revision of article; R.M.M. Gevers: critical revision of article; M. Boulaksil: critical revision of article and design of figures.
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Conflict of interest
The authors declare that they have no conflict of interest.
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