| Home | E-Submission | Sitemap | Contact us |  
top_img
International Journal of Arrhythmia 2014;15(3): 69-71.
ECG & EP CASES
Right Heart Penetration Injury by
Screw-In Pacing Leads





   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

  1. Carlson MD, Freedman RA, Levine PA. Lead perforation: incidence in registries. Pacing Clin Electrophysiol. 2008;31:13-15.
  2. 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.
  3. 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.
TOOLS
PDF Links  PDF Links
Full text via DOI  Full text via DOI
Download Citation  Download Citation
  E-Mail
Share:      
METRICS
1,678
View
21
Download