Delayed Perforation of a Right Ventricular ICD Lead Following Subacute Pleuritis

Abstract

A 75-year-old woman with sarcoidosis developed frequent ventricular premature contractions. Active accumulation was demonstrated in her heart by a positron-emission tomography scan, and an implantable cardioverter-defibrillator (ICD) was implanted for primary prevention. The right ventricular (RV) lead sensing threshold deteriorated from 5.5 mV to 2.6 mV the next day. Because the pacing threshold and lead impedance were kept normal and the sensing threshold did not decrease any further, she was discharged one week later. She developed chest pain three days after discharge and a left plural effusion was detected by a chest X-ray in another hospital and antibiotics were prescribed with the diagnosis of pleuritis. Although the pleuritis improved within a week, the RV lead pacing threshold became elevated to 7.5 V and a lead perforation was detected by a CT scan two months after the ICD implantation. The RV lead was extracted surgically. When the pericardium was opened, a small amount of a hemorrhagic effusion appeared and the tip of the lead was jumping in and out through the pericardial fat. Another ICD was re-implanted the next day. A transient pleural effusion after an ICD implantation might be an early warning sign of a delayed lead perforation.