SESSION TITLE: Cardiothoracic Interventions 2SESSION TYPE: Rapid Fire Case ReportsPRESENTED ON: 10/18/2022 10:15 am - 11:10 amINTRODUCTION: Delayed lead perforation (DLP), defined as lead perforation occurring > 30 days after cardiac implantable electronic devices (CIEDs) implantation, and persistent left superior vena cava (PLSVC), a vascular anomaly between the left subclavian and jugular veins and the coronary sinus (CS) draining into the right atrium (RA), is an extremely rare coinciding cardiac pathology. Prevalence rates for RA perforation from pacemaker lead placement and presence of PLSVC in the healthy population are 0.1 - 0.8 % and 0.2 - 3.0 %, respectively [1,2].CASE PRESENTATION: A 71-year-old man with a history of congestive heart failure, dilated non-ischemic cardiomyopathy, chronic left bundle branch block (LBBB) and inducible monomorphic ventricular flutter underwent an attempted Biventricular Implantable Cardioverter Defibrillator (BiV ICD) placement. The RV defibrillation lead was implanted through the PLSVC; however, the CS lead implantation was more challenging. Fluoroscopic attempts using multiple catheters with the aid of a 4F quadripolar pacing electrode catheter were unsuccessful at the CS lead implantation. Subsequently, the RA pacing lead was implanted with active fixation to the low lateral RA wall. Six months later, the patient presented with acute dyspnea, orthopnea and pleuritic chest pain. EKG showed sinus tachycardia and chronic LBBB without acute ST-T wave abnormalities. Chest X-ray and CT Chest showed a large right-sided pneumothorax, prompting emergent chest tube placement. Echocardiography revealed an LVEF of 58 % without tamponade. The ICD interrogation showed an increased RA lead impedance. After multidisciplinary discussion, the patient underwent a successful RA lead extraction with plugging of the RA port. The patient tolerated the procedure well, and remained asymptomatic on follow-up evaluation.DISCUSSION: The mechanism underlying DLP is not well-understood, although several risk predictors exist including active lead fixation, location and type of lead placement, long-term anticoagulation use, steroid use, old age, female sex, and low body weight [3]. In this case, pericardial irritation from active fixation, repetitive mechanical irritation from suboptimal RA lead placement and increased tension in the RA lead secondary to PLSVC presence are potential explanations for RA perforation. The management of RA perforation can be approached percutaneously with lead extraction in the electrophysiology laboratory with surgical backup on standby given the risk of hemodynamic collapse.CONCLUSIONS: This case highlights technical challenges and rare complications associated with CIEDs. Such cases demand a careful review of existing risk predictors, clinical significance of vascular anomalies and a high clinical suspicion with prompt recognition of life-threatening complications of CIEDs to improve patient outcomes.Reference #1: Khan MN, Joseph G, Khaykin Y, Ziada KM, Wilkoff BL. Delayed lead perforation: a disturbing trend. Pacing Clin Electrophysiol. 2005;28(3):251-253. doi:10.1111/j.1540-8159.2005.40003.xReference #2: Perles Z, Nir A, Gavri S, et al. Prevalence of persistent superior vena cava and association with congenital heart anomalies. Am J Cardiol. 2013;112(8):1214-1218. doi:10.1016/j.amjcard.2013.05.079Reference #3: Khoueiry G, Lakhani M, Abi Rafeh N, et al. Right coronary artery fistula as a result of delayed right atrial perforation by a passive fixation lead. Circ Arrhythm Electrophysiol. 2012;5(2):e46-e47. doi:10.1161/CIRCEP.111.970376DISCLOSURES: No relevant relationships by Ravi GurujalNo relevant relationships by Palaniappan MuthappanNo relevant relationships by Akruti PrabhakarNo relevant relationships by Abdul Wase SESSION TITLE: Cardiothoracic Interventions 2 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Delayed lead perforation (DLP), defined as lead perforation occurring > 30 days after cardiac implantable electronic devices (CIEDs) implantation, and persistent left superior vena cava (PLSVC), a vascular anomaly between the left subclavian and jugular veins and the coronary sinus (CS) draining into the right atrium (RA), is an extremely rare coinciding cardiac pathology. Prevalence rates for RA perforation from pacemaker lead placement and presence of PLSVC in the healthy population are 0.1 - 0.8 % and 0.2 - 3.0 %, respectively [1,2]. CASE PRESENTATION: A 71-year-old man with a history of congestive heart failure, dilated non-ischemic cardiomyopathy, chronic left bundle branch block (LBBB) and inducible monomorphic ventricular flutter underwent an attempted Biventricular Implantable Cardioverter Defibrillator (BiV ICD) placement. The RV defibrillation lead was implanted through the PLSVC; however, the CS lead implantation was more challenging. Fluoroscopic attempts using multiple catheters with the aid of a 4F quadripolar pacing electrode catheter were unsuccessful at the CS lead implantation. Subsequently, the RA pacing lead was implanted with active fixation to the low lateral RA wall. Six months later, the patient presented with acute dyspnea, orthopnea and pleuritic chest pain. EKG showed sinus tachycardia and chronic LBBB without acute ST-T wave abnormalities. Chest X-ray and CT Chest showed a large right-sided pneumothorax, prompting emergent chest tube placement. Echocardiography revealed an LVEF of 58 % without tamponade. The ICD interrogation showed an increased RA lead impedance. After multidisciplinary discussion, the patient underwent a successful RA lead extraction with plugging of the RA port. The patient tolerated the procedure well, and remained asymptomatic on follow-up evaluation. DISCUSSION: The mechanism underlying DLP is not well-understood, although several risk predictors exist including active lead fixation, location and type of lead placement, long-term anticoagulation use, steroid use, old age, female sex, and low body weight [3]. In this case, pericardial irritation from active fixation, repetitive mechanical irritation from suboptimal RA lead placement and increased tension in the RA lead secondary to PLSVC presence are potential explanations for RA perforation. The management of RA perforation can be approached percutaneously with lead extraction in the electrophysiology laboratory with surgical backup on standby given the risk of hemodynamic collapse. CONCLUSIONS: This case highlights technical challenges and rare complications associated with CIEDs. Such cases demand a careful review of existing risk predictors, clinical significance of vascular anomalies and a high clinical suspicion with prompt recognition of life-threatening complications of CIEDs to improve patient outcomes. Reference #1: Khan MN, Joseph G, Khaykin Y, Ziada KM, Wilkoff BL. Delayed lead perforation: a disturbing trend. Pacing Clin Electrophysiol. 2005;28(3):251-253. doi:10.1111/j.1540-8159.2005.40003.x Reference #2: Perles Z, Nir A, Gavri S, et al. Prevalence of persistent superior vena cava and association with congenital heart anomalies. Am J Cardiol. 2013;112(8):1214-1218. doi:10.1016/j.amjcard.2013.05.079 Reference #3: Khoueiry G, Lakhani M, Abi Rafeh N, et al. Right coronary artery fistula as a result of delayed right atrial perforation by a passive fixation lead. Circ Arrhythm Electrophysiol. 2012;5(2):e46-e47. doi:10.1161/CIRCEP.111.970376 DISCLOSURES: No relevant relationships by Ravi Gurujal No relevant relationships by Palaniappan Muthappan No relevant relationships by Akruti Prabhakar No relevant relationships by Abdul Wase