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International Journal of Arrhythmia 2014;15(3): 69-71.
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| ECG & EP CASES |
Right Heart Penetration Injury by
Screw-In Pacing Leads |
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Introduction
Right heart perforation is a rare (＜1%) complication
of cardiac pacemaker implantation
procedures.1 We report two cases of right heart
microperforation related to the use of screw-in
pacing leads.
Case 1
A 45-year-old male patient with Brugada
syndrome underwent dual chamber implantable
cardioverter defibrillator (ICD) implantation for
secondary prevention of sudden cardiac arrest.
A screw-in pacing lead (CapSure®, Medtronic,
MP, USA) was actively fixed at the right atrial
appendage under fluoroscopic guidance. During
ICD implantation, the patient did not complain
of any chest discomfort. The procedure was
completed without immediate or overt complications.
However, 3 days later the patient began
to complain of mild chest pain radiating towards
the right shoulder. The patient described the
chest pain as usually triggered by deep inspiration,
coughing, or a change in body position.
The sensing and pacing parameter values were
normal. No abnormal findings were detected by
physical, chest radiography, fluoroscopy, and echocardiography examinations. The intensity of
the chest pain increased gradually despite ibuprofen
and cefazolin administration over 2 weeks.
Chest computed tomography (CT) performed 2
weeks after the implantation procedure showed
the screw of the pacing lead penetrating the right
atrial pericardium (Figure 1). We tried to reposition
the right atrial lead to reduce chest pain and
avoid overt perforation. Unfortunately, active
fixation of the screw lead at other sites within the
right atrium repeatedly induced chest pain, which
was aggravated by deep inspiration and coughing.
Therefore, the right atrial lead was removed.
Subsequently, the chest pain decreased gradually
and completely disappeared 2 weeks later. The
patient was discharged without any other complications.
Case 2
A 65-year-old male patient underwent dual chamber pacemaker implantation for sick sinus
syndrome. Screw-in pacing leads (CapSure®,
Medtronic, MP, USA) were actively fixed at the
right atrial appendage and upper interventricular
septum under fluoroscopic guidance. During
the pacemaker implantation procedure, the patient
did not complain of any chest discomfort
and the procedure was completed without overt
complications. One day after the implantation
procedure, the patient began to complain of leftsided
chest pain and epigastric pain. The patient
described the chest and epigastric pain as being
exacerbated upon standing up. The sensing and
pacing parameter values were normal. No abnormal
findings were detected by physical, chest
radiography, fluoroscopy, echocardiography, or
endoscopy examinations. The intensity of the
pain increased gradually despite ibuprofen, cefazolin,
and esomeprazole administration over
2 weeks. Chest CT performed 2 weeks after the
implantation procedure showed the right atrial(arrowhead) and ventricular (arrow) lead tips very
close to the pericardium, suggestive of pericardial
penetration injury by the screws (Figure 2). Although
no other complications were detected by
chest CT, we had to remove the old screw leads
and reinsert the new tined leads for differential
diagnosis of the chest and epigastric pain. Immediately
after the lead reinsertion procedure, the
chest and epigastric pain decreased dramatically.
Penetration of the pericardium by the screws of
the right atrial or ventricular leads was regarded
as the cause of chest and radiating epigastric
pain. The patient was discharged without other
complications.
Discussion
Overt right heart perforation, which requires
invasive intervention is a rare complication of
cardiac pacemaker implantation procedures.
Asymptomatic cardiac perforation detected by
chest CT is much more common (up to 15% of
the patients with pacemaker or ICD) than symptomatic
cardiac perforation.2 Right atrial leads,
right ventricular ICD leads, and the use of active
fixation leads are related with a higher incidence
of cardiac perforation.2,3 If cardiac perforation is
mild and not complicated by major vascular complications
such as cardiac tamponade, it can be
difficult to evaluate for perforation using routine
chest radiography, fluoroscopy, and echocardiography
examinations. The sensing and pacing
parameter values may be normal. Although chest
CT can detect pericardial penetration, it is not
always possible. If a patient complains of chest
pain with clinical characteristics indicative of
pericardial origin after a cardiac device implantation
procedure, the probability of perforation
should be strongly suspected. We report 2 cases
of pericardial penetration by the screw of an active
fixation lead to remind physicians to consider
cardiac perforation as a cause of new onset chest
pain in patients who underwent cardiac device
implantation.
References
- Carlson MD, Freedman RA, Levine PA. Lead perforation: incidence in registries.
Pacing Clin Electrophysiol. 2008;31:13-15.
- Hirschl DA, Jain VR, Spindola-Franco H, Gross JN, Haramati LB. Prevalence and characterization of asymptomatic pacemaker and ICD lead perforation on CT.
Pacing Clin Electrophysiol. 2007;30:28-32.
- Danik SB, Mansour M, Singh J, Reddy VY, Ellinor PT, Milan D, Heist EK, d'Avila A, Ruskin JN, Mela T. Increased incidence of subacute lead perforation noted with one implantable cardioverter-defibrillator.
Heart Rhythm. 2007;4:439-442.
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