Extra-Thoracic Lead: Extreme Pacing Lead Perforation into the Breast

Abstract

An eighty-three year-old woman presented to the emergency department with a painful breast lump. Her medical history included coronary artery bypass with mitral valve replacement and permanent pacemaker insertion ten years ago. Twelve months earlier, her pacemaker was upgraded to a biventricular automatic implantable cardioverter-defibrillator (BiV-AICD). Ultrasonography revealed her right ventricular (RV) pacing lead was within the left breast, and sited within a 26 x 12 x 17 mm fluctuant collection moving with apical impulse. Computed tomography confirmed bipolar lead erosion through the right ventricular apex, the pericardium and the intercostal space into the subcutaneous fat of the left breast. Our patient proceeded to surgery, performed via submammary incision with dissection down to the lead. Thirty millilitres of purulent fluid was drained and cultured Staphylococcus epidermidis. The RV lead was successfully repositioned and the apex repaired. Our patient was discharged nineteen days later on lifelong antibiotics, and remains well. There are multiple case reports of pacing lead perforation, with varying degrees of fatality. Our case represents one of the most extreme survivable lead perforations ever reported. Lead perforation has been variously reported into the right coronary artery, the lungs, the pleural cavity, the breast, the diaphragm, and even the colon. AICD leads, older age and female gender have all been consistently identified as higher-risk features for late lead perforation.