CASE REPORT

Late Right Ventricular Perforation After PermanentPacemaker Implantation: How Far Can the Lead Go?AHMED SANOUSSI, BADIH EL NAKADI, INES LARDINOIS, YASMINE DE BRUYNE,and MARC JORISFrom the Department of Cardiac Surgery, Charleroi University Hospital, Belgium

Sanoussi, A., ET AL.: Late Right Ventricular Perforation After Permanent Pacemaker Implantation: HowFar Can the Lead Go? This case report describes the incredible dislocation of a right ventricular lead 1month after pacemaker implantation. The lead’s tip was found in the subcutaneous fat beneath the leftbreast. Extraction was uneventful. The key steps in the diagnosis and management of this rare complicationare discussed. (PACE 2005; 28:723–725)

pacemaker, right ventricular perforation, lead dislocation

Case ReportA 79-year-old female was transferred to our

department for the management of a right ventric-ular lead dislocation. In October 2002, she pre-sented an atrial fibrillation complicated by a stroke

Address for reprints: Badih El Nakadi, M.D., Servicede Chirurgie Cardiaque, C.H.U Charleroi, Bld Zoe Drion,1, 6000 Charleroi, Belgium. Fax: +3271921147; e-mail:badih.elnakadi@chu-charleroi.be

Received July 1, 2004; revised February 28, 2005; acceptedApril 7, 2005.

Figure 1. (A) Chest x-ray on the day of primary implantation showing important stress on theventricular lead (black dots). (B) Chest x-ray on admission to our department.

with a rapid regression of symptoms. The treat-ment was started with Sotalol (160 mg b.i.d.) andCoumarin. A dual chamber rate responsive pace-maker (Selection 9000, Vitatron VB, Arnherm, theNetherlands) and bipolar tined tip leads (Vitatron,Crystalline ICL 08 B in the ventricle) were im-planted for bradycardia and sick sinus syndrome(Fig. 1A). One month after implantation, she pre-sented an episode of acute pain of the anterior lefthemithorax. Her family doctor diagnosed an inter-costal neuralgia. Three weeks later she attendedthe pacemaker control visit. The ECG showed fail-ure of ventricular sensing and pacing. The chest

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Figure 2. Thoracic CT scan showing the ventricular lead passing through the myocardium (arrow, A), the pericardium(arrow, B), the intercostal space (arrow, C), and ending in the subcutaneous fat (arrow, D).

x-ray revealed a migration of the ventricular leadthrough the pericardium (Fig. 1B). There was nopericardial effusion on transthoracic echocardiog-raphy.

Once, in our department, a thoracic CT scanwas done to localize the lead’s tip, which wasfound in the subcutaneous fat underneath the leftbreast (Fig. 2)! The patient was operated under gen-eral anesthesia and transesophageal echocardiog-raphy (TEE) monitoring. The lead’s tip was easilyfound and transected through a small incision inthe left submammary fold (Fig. 3). The proximalpart of the lead was then dissected free and the leadeasily explanted. A new lead (Medtronic, model:CapSurefix Novus 5076) was implanted in the ven-tricular septum. The patient was discharged on thesecond postoperative day with a normal chest x-ray and TTE control.

DiscussionAcute myocardial perforation has been re-

ported to occur in 1–7% of pacemaker implanta-tion.1–2 Today’s pacing leads are smaller and moreflexible, leading to a decrease in the incidence ofacute perforation to less than 1%.5 Late perfora-tion is less well recognized as a classical com-

plication of device implantation.6 It is believedto be very rare. In this case, it is clear that theexcess of length of the ventricular lead seen onthe first chest x-ray is the reason why the elec-trode was propelled all the way into the subcuta-neous fat. Although some slack on the ventricularlead is important to avoid traction or displacement

Figure 3. The lead’s tip lying in the subcutaneous fat.

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in the upright position, too much slack providesexcessive tension on the electrode and leads toperforation.

Many reports have highlighted various facetsof this complication. The clinical presentation var-ied widely, from asymptomatic patients to suddencardiac death, indicating the importance of a highdegree of suspicion. A history of prior device im-plantation and chest pain, diaphragmatic pacing,or pericardial friction rubs makes the diagnosisvery likely.3

The ECG pattern of intermittent or failed car-diac pacing, eventually with the pacemaker arti-fact still present and no apparent electrode dis-placement on the chest x-ray, should alert thephysician. Sometimes, pacing failure may occurwhile the sensing function is retained. In this pa-tient, the ECG showed failure of ventricular pacingand sensing.

Chest x-ray can suggest myocardial perfora-tion. It is suspected when a distance less than 3mm separates the tip from a fine radiolucent stripeof epicardial fat.5

In our case, perforation was obvious on chestx-ray as the lead’s tip was outside the heartshadow. CT scan was very helpful in precising thetip’s position, and thus managing the surgical treat-ment.

The question in the management of myocar-dial perforation is whether to remove the lead ornot, and if yes, how to do it. In cases of acute per-foration, repositioning the lead and serial echocar-diography follow-up are sufficient in most cases.Surgical closure is uncommon.3 In cases of lateperforation, the electrode may be firmly adherentand the removal would be quite risky. If the lead’stip is inside the mediastinum and there is no bleed-ing complication, an additional lead could be in-serted without performing lead extraction. When-ever an uncontrolled bleeding occurs or when alead migrates outside the pericardium with a po-tential risk of vascular or pulmonary damage, ex-traction must be performed. In our department, theprocedure depends on the lead’s type. If the leadhas an active fixation tip, we consider the primar-ily transvenous extraction under TEE monitoringand general anesthesia as the treatment of choicebecause of the low risk of complications. On theother hand, tined electrodes have bulky tips thatmay damage tissues during withdrawal. In suchcases, a two-stage surgery is generally considered.Cutting the lead’s tip first decreases the risk ofbleeding or damaging tissues during extraction.Moreover, pulling back the remainder of the leadtransvenously becomes easy, without any need foran extraction device.

References1. Kiviniemi MS, Pirnes MA, Eranen HJK, et al. Complications related

to permanent pacemaker therapy. PACE 1999; 22:711–720.2. Trigano JA, Paganelli F, Richard P, et al. Perforation du Cœur apres

Implantation Transveineuse de Stimulation Cardiaque. Presse Med1999; 28:836–840.

3. Asano M, Mishima A, Ishii T, et al. Surgical treatment for right ven-tricular perforation caused by transvenous pacing electrodes: A re-port of three cases. Jpn J Surg 1996; 26:933–935.

4. Ellenbogen KA, Wood MA, Shepard RK. Delayed complications fol-lowing pacemaker implantation. PACE 2002; 25:1155–1158.

5. Kautzner J, Bytesnik J. Recurrent pericardial chest pain: A case oflate right ventricular perforation after implantation of a transvenousactive-fixation ICD lead. PACE 2001; 24:116–118.

6. Mond Harry G, Stuckey John G, Sloman Graeme. The diagnosis ofright ventricular perforation by an endocardial pacemaker electrode.PACE 1978; 1:62–67.

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