We report an 84-year-old woman who presented with right ventricular perforation 4 days after pacemaker implantation for syncope due to sick sinus syndrome. Median sternotomy revealed no pericardial effusion, but the pacing lead had penetrated the right ventricle and pericardium. When the pleura was opened, the tip of the lead was seen in the visceral pleura. The lead was cut in the pericardial cavity and extracted from the left subclavian wound together with the generator. The right ventricular perforation was sutured and a temporary pacing lead was placed on the right ventricular wall intraoperatively. Ten days after the surgery, a new pacemaker lead was placed in the ventricular septum via the right axillary vein. Right ventricular perforation is a rare complication after pacemaker implantation. Typically, it occurs at the time of implantation or within 24 hours after implantation. In the present case, the perforation of the right ventricle which needed urgent surgery occurred 4 days after implanting the pacing lead at the right ventricular apex. Great care should have been taken not to overlook this life-threatening complication even more than 24 hours after pacemaker implantation.
Cardiac perforation by a pacing lead is rare, but life-threatening complication of pacemaker implantation usually presents within 24 hours of implantation and is uncommon after that. This complication tends to be more frequent when the tip of the pacing lead is placed at the right ventricular (RV) apex rather than the ventricular septum [
An 84-year-old woman with a history of syncope was referred to a general hospital by her primary doctor. Sick sinus syndrome was diagnosed and a ventricular demand pacemaker was implanted via the left axillary vein. The tip of the implanted lead (5076-52 cm, Medtronic, Minneapolis, MN) was a screw type. The lateral chest X-ray film obtained just after pacemaker implantation demonstrated that the tip of the lead was in the correct position (Figure
Lateral chest X-ray film demonstrating the position of the lead. (a) Just after the surgery. The tip of the lead was in the correct position. (b) Four days after the surgery. The tip of the lead intruded into the chest wall.
Chest CT reveals perforation of the right ventricle by the lead.
Intraoperative view of the lead penetrating the right ventricular apex.
The incidence of perforation of the heart by the pacing lead after pacemaker implantation ranges from 0.1% to 0.8% [
There are two options for the management of ventricular perforation by a pacemaker lead, which are surgical or transvenous procedures. According to a review of 25 patients by Refaat et al. [
Amara et al. reported that there was a higher risk of cardiac perforation in thin elderly female patients, as well as patients on anticoagulants or steroids [
A change in the pacing threshold can be a sign of RV perforation by the pacemaker lead. While a chest X-ray film is convenient for detecting displacement of the lead, CT should subsequently be performed for accurate diagnosis if RV perforation seems likely.
To reduce the risk of RV perforation, placing the tip of the lead at the ventricular septum is recommended rather than implantation in the RV apex or free wall. This is because the ventricular septum is typically thicker than either the RV apex or free wall, and even if a pacing lead penetrates the septum the tip will remain in the left ventricular chamber.
RV perforation is a rare, but potentially fatal, complication of pacemaker implantation. It usually manifests within 24 hours, but our patient presented four days after implantation. This case emphasizes that careful postoperative observation is necessary, even if the pacing lead is positioned correctly. To avoid RV perforation, implantation of the pacemaker lead at the ventricular septum seems to be safer than selecting the RV apex or free wall.
The authors declare that they have no conflicts of interest.
The authors are grateful to Yoko Motomura for her assistance in preparing the manuscript.