Lead perforation: An uncommon cause of chest pain in a patient with pacemaker

Abstract

Fig. 1. Pacemaker wire in the right ventricle close to the apex, also note moderate sized pericardial effusion. We thank Chen et al. [1] for their article regarding right ventricular septal perforation from an active fixation lead. This was very interesting, as usual for International Journal of Cardiology. We also recently had a 56-year-oldmalewhopresented to our emergency department with a 30-minute history of midsternal, stabbing chest pain. He underwent permanent pacemaker insertion 2 days prior to this presentation for third degree heart block. His vital signs and physical examination were unremarkable. His chest X-ray showed stable cardiomegaly without any pulmonary pathology. Electrocardiography revealed old left bundle branch block with a paced rhythm. Bedside transthoracic echocardiography was urgently obtained, revealing a moderate sized circumferential pericardial effusion and displacement of right ventricular (RV) pacer lead perforating through the apex (Figs. 1 and 2). The patient underwent emergent cardiac surgery which revealed 250 ml of blood in the pericardial space. His pacemaker wire was pulled back. The patient had an uncomplicated post-op course and was discharged to home in a stable condition. Lead perforation is an infrequent but potentially fatal complication of pacemaker implantation with published rate of 0.1–0.8% [2,3]. Patients with this complication typically present with recurring, stabbing chest pain and usually present within 1 month after implantation [3,4]. Transthoracic echocardiography is the initial diagnostic test of choice as it usually provides a clear visualization of the position of the lead tip as well as associated pericardial effusion. Chest computed tomography scan can be used if the initial echocardiography is not diagnostic [5]. Management of lead perforation depends on the patient's hemodynamic status. In a patient with hemodynamic instability or with rapid progression of pericardial effusion, surgical repair is generally mandated while simple direct traction with close echocardiographic