Unusual presentation of asymptomatic subacute lead-related ventricular perforation beyond the pericardium without pericardial effusion: a case report

Abstract

The clinical manifestations of subacute pacemaker lead-related cardiac perforations are highly variable. Patients with subacute perforations can present with a variety of symptoms, whereas those with acute perforations usually present with cardiac tamponade that necessitates emergent pericardiocentesis. A 32-year-old woman underwent pacemaker implantation for sick sinus syndrome. An active-fixation atrial lead was fixed to the right atrial appendage, and a ventricular lead was fixed to the right ventricle (RV) apex, with acceptable parameters. Two weeks postoperative, the patient visited the clinic for routine examination of the pacemaker parameters. Chest X-ray showed migration of the RV lead beyond the cardiac silhouette. Echocardiography revealed no evidence of pericardial effusion or tamponade. Computed tomography revealed that the RV lead was positioned beyond the RV and pericardium and into the anterior chest wall. Procedural lead revision was performed with cardiothoracic surgery backup. The lead was retracted after loosening the active-fixation screw and inserting the stylet. The lead was placed in the RV septum with active fixation. The procedure was completed without complications, and the patient was discharged after 3 days. Subacute lead perforations can present with various symptoms, and some patients may be asymptomatic without pericardial effusion. Altered lead parameters frequently provide the first indication for the diagnosis of cardiac perforation. Transvenous lead revision with surgical backup is an alternative to surgical extraction.