A case of a delayed perforation of the right ventricle by the pacemaker lead in a 67-year-old woman is presented. Perforation,

mimicking stenocardial symptoms, was incidentally diagnosed on a computed tomography chest scan. Percutaneous lead extraction

was successfully performed, with simultaneous implantation of a new pacemaker lead

Czajkowski, Marek

Klimeczek, Piotr

Kutarski, Andrzej

Lelakowski, Jacek

Małecka, Barbara

Pasowicz, Mieczysław

Rydlewska, Anna

Ząbek, Andrzej

Kardiologia Polska

English

Jagiellonian Univeristy Repository

Kardiologia Polska 2010; 68: 3Delayed perforation of the right ventricle as a complicationof permanent cardiac pacing – is following the guidelinesalways the right choice? Non-standard treatment – a casereport and literature reviewPóźna perforacja prawej komory jako powikłanie stałej stymulacji serca – czy przestrzeganie wytycznych jest zawsze właściwym wyborem? Postępowanie niestandardowe – opis przypadku i przegląd piśmiennictwaAnna Rydlewska1, Barbara Małecka1, Andrzej Ząbek1, Piotr Klimeczek2, Jacek Lelakowski1, Mieczysław Pasowicz2, Marek Czajkowski3, Andrzej Kutarski41 Department of Electrocardiology, The John Paul II Hospital, Krakow 2 Center for Diagnosis, Prevention and Telemedicine with One-Day Diagnostic Unit, The John Paul II Hospital, Krakow 3 Department of Cardiology, Medical University, Lublin4 Department of Cardiosurgery, Medical University, LublinA b s t r a c tA case of a delayed perforation of the right ventricle by the pacemaker lead in a 67-year-old woman is presented. Perforation,mimicking stenocardial symptoms, was incidentally diagnosed on a computed tomography chest scan. Percutaneous lead extractionwas successfully performed, with simultaneous implantation of a new pacemaker lead.Key words: permanent heart stimulation, complication, delayed perforation of the right ventricleKardiol Pol 2010; 68: 357-361Address for corespondence:Andrzej Ząbek MD, Oddział Kliniczny Elektrokardiologii, Krakowski Szpital Specjalistyczny im. Jana Pawła II, ul. Prądnicka 80, 31-202 Kraków, tel.: +48 12 614 20 00, e-mail: andrzej_j_z@poczta.onet.pl Elektrofizjologia inwazyjna/Invasive electrophysiologyIntroductionHeart perforation is a rare complication of pacemakerimplantation. Acute, subacute and delayed leadperforations have been defined. Acute lead perforationoccurs within 24 h after implantation and is considered tobe associated with more severe clinical presentation: hearttamponade or even death. Subacute and delayed perforations are defined incontrast to acute perforation; to diagnose them normalchest X-ray and electrical parameters within 24 h afterimplantation are required [1]. Subacute and delayedperforations are differentiated according to whether thetime of their presentation is over one month afterimplantation. Incidence of delayed lead perforation hasbeen estimated by Khan et al. at 0.1-0.8% for pacemakerimplantation and 0.6-5.2% in ICDs [2].Probably the lower incidence and more benign clinicalpresentation in delayed perforations is associated with‘self-sealing’ properties of the ventricle wall: by fibrosis,muscle contraction or by the lead itself [3, 4].Risk factors of lead perforation have not been definedyet. The type of lead used might influence the incidenceof perforation. It occurs more often in the case of thefollowing leads:1. for temporary stimulation,2. atrial,3. with active fixation system,4. defibrillator leads, with double spirals (more wires, stiffer),5. when excessive length during implantation is left,6. small diameter (increased force per unit area),7. so-called high resistance (small tip surface).Kardiologia Polska 2010; 68: 3358 Anna Rydlewska et al.There have been many reports of a higher perforationrate for certain lead types (e.g. Riata ST Jude Medical leads),which might indicate that certain constructive propertiesof these leads are associated with increased perforationrisk, but it has not been proved in any larger trial [1, 5-8]. Also the lead tip location is a factor. Perforations occurmore frequently in the apical location, as compared withseptal position or in the right ventricular outflow tract,which is probably due to the thinner muscle in the rightventricle apex [1, 2, 6, 9-11].Apart from the lead type and its location, also the heartmuscle itself may favour perforation. There has been a casereport on perforation in a patient with congenitalcardiomyopathy [12]. Anticoagulation therapy and steroiduse within 7 days of implantation may also have a negativeimpact. The elderly, women, and patients with low bodymass (BMI < 20 kg/m2) are also prone to perforation [6, 9].In the case of defibrillator leads, the perforation raterises with the number of shocks delivered [5]. Chesttrauma, especially soon after implantation, may alsoindicate a necessity to exclude perforation [5, 10].Subacute and delayed right ventricle perforation mayhave various clinical presentations, from incidentallydiagnosed asymptomatic perforation to death [1-16, 18,19]. The following clinical symptoms of lead perforationhave been described:1. chest pain,2. dyspnoea,3. syncope (due to improper stimulation or its completefailure),4. inadequate ICD shocks,5. muscle or diaphragm stimulation,6. abdominal pain (due to diaphragm stimulation or leadmigration to the peritoneal cavity),7. hiccup (as a symptom of phrenic nerve stimulation),8. mammary haematoma,9. consequences of diaphragm, lung, chest wallperforation,10. pleural or pericardial effusion, rarely demandingdrainage.The most common symptom described in the literaturehas been the failure of the leads to pace or senseappropriately [1-3, 5-16, 18, 19]. Decreased lead impedanceand R-wave amplitude, as well as increased pacing threshold(or even failure to pace), are the most widely describedobservations. However, there have been some reports ondelayed perforations with normal electrophysiologicalparameters [4]. Therefore, a conclusion may be made thatwhereas improper pacemaker function may indicateperforation, its normal function does not exclude it.Visualisation is an important stage in perforationdiagnosis. The key tests are: chest X-ray, transthoracic (TTE)or transoesophageal (TEE) echocardiography and computedtomography. The X-ray may show the lead’s migrationoutside the heart: into the pleural cavity, peritoneal cavityor to the chest wall. It also allows assessment of pleuraleffusion. Perforation is suspected when less than 3 mmseparate the lead tip from the epicardial fat [13].Echocardiography may show lead presence in thepericardial sac or pericardial effusion. However, it is oftenfalse negative, showing no pericardial effusion, or noevidence of the lead’s migration, while the perforation isconfirmed in other tests [1, 2, 12-15].Computed tomography (CT) in the perforationdiagnosis seems to play a crucial role, becoming a goldenstandard in its visualisation [1, 5, 6, 14, 15]. Cases ofasymptomatic perforations identified on CT scans,performed for other medical indications, are described inthe literature. Perforation rates were 15% for atrial leadsand 6% for ventricular leads. Small pericardial effusion inpatients with and without perforation have been presentin 20 and 19% respectively [4].Case reportA 67-year-old woman with coronary heart disease riskfactors – overweight, smoking cigarettes, with arterialhypertension and hyperlipidaemia – had a CT scan of thecoronary arteries performed due to uncharacteristic chestpain.Three years before she had undergone atrioventricularpacemaker implantation [pacemaker DDDR-VitatronC60DR, atrial lead Biotronic Selox JT 53 implanted in theauricle of the right atrium and ventricular lead with activefixation system Vitatron Cristalline Actifix ICF 09Bimplanted on the anterior wall of the right ventricularoutflow tract (RVOT)] because of sick sinus syndrome withatrioventricular block. During implantation normal sensingand pacing parameters were achieved, and post-implantation X-ray showed normal lead position.After the implantation, the patient complained ofpersistent, uncharacteristic chest pain. The pain wasstabbing, localised in the apex and retrosternal region, notassociated with physical exercise nor body position. Regular telemetric control (every 6 months) showednormal pacemaker function. Considering the uncharac-teristic symptoms and cardiovascular risk factors, coro-nary heart disease diagnostics was performed. The TTEperformed in April 2009 showed no evident pathologies,and, significantly, no pericardial effusion.Angio-CT of the coronary arteries performed in August2009 showed the lead tip outside the right ventricle, in theventricle wall and partially in the pericardial sack (Figure 1).The patient was admitted to hospital and furtherdiagnosis was performed. On admission, the patient washaemodynamically stable. The pacemaker control presentednormal sensing and pacing parameters. Chest X-ray showedno dislocation of the leads. The TTE revealed pericardialeffusion up to 24 mm behind the right ventricle, the inferiorand posterior wall, with mobile localisation of the lead tip,with no evident penetration to the pericardium and with theKardiologia Polska 2010; 68: 3359Delayed perforation of the right ventricle as a complication of permanent heart stimulation blood flow between the right ventricle and the pericardiumvisualised by the colour Doppler spectrum (Figure 2).During the following days of hospitalisation, thepatient was monitored echocardiographically: slightregression in the quantity of pericardial effusion wasnoted (to 16 mm behind the right ventricle and the inferiorwall) and signs of effusion organisation were observed.Telemetric control of the pacemaker showed its normalfunction. Considering the overall clinical picture and theavailable literature, it was decided to performpercutaneous lead extraction with cardiosurgical backupand with simultaneous new lead implantation. A BFigure 2. TTE before the removal procedure: A – visible lead in the right ventricle with probable perforation tothe pericardium (arrow); B – liquid in the pericardium up to 24 mm behind the left ventricular posterior walland up to 18 mm before the right ventricular anterior wall (arrows). Arrow 1 – pacemaker lead; C – blood flowbetween liquid space in the pericardium (arrow 2) and right ventricle lumen in Doppler examination (arrow 1)Ao – aorta, LA – left atrium, LV – left ventricle, RV – right ventricleB CAFigure 1. Picture of the heart in CT. A – visible perforation by ventricular lead to the pericardium (arrow); B – volume digital reconstruction: visible 2 leads of atrioventricular stimulation system. Ventricular lead is inthe RVOT. Lead’s tip is visible outside the outline of the heart in the pericardium (arrow)Kardiologia Polska 2010; 68: 3360 Anna Rydlewska et al.The patient was transported to the centre specializingin percutaneous lead extraction. In the operating room, withbasic live function monitoring, with anaesthesiological,cardiosurgical and echocardiographic backup, right ventriclelead percutaneous extraction was performed. The procedure was performed through the leftsubclavian vein, using green polypropylene Byrd dilatorsheaths (10.0/12.1 F), to separate the lead from theadhesions to the vessels and heart. In order to stiffen thelead during its extraction, a stylet without anchoringfunction was used. The lead was removed withoutcomplications, and no symptoms of tamponade wereobserved during or after the procedure. Simultaneously,a new active fixation lead was implanted in the middlepart of the ventricular septum. The patient was dischargedin a good general condition. In the follow-up, thesymptoms began to retreat. In the TTE performed 2 weeksafter the procedure, small effusion was seen (up to 9 mmbehind the right ventricle, the inferior and posterior wall)(Figure 3).DiscussionMost authors agree that the best method of leadperforation treatment is percutaneous extraction in theoperating room with TTE and TEE monitoring during and/orafter the procedure, with the cardiosurgical andanaesthesiological team ready to intervene, even if sucha necessity is rare [1, 2, 8, 14, 16, 19]. Such practice isinconsistent with the HRS expert consensus (2009), whichclassifies percutaneous lead extraction as class IIIindication, level of evidence C [17]. Percutaneous extractionof the perforating lead, as not requiring generalanaesthesia, has been performed in case of a very highoperation risk [12]. Described cases of open surgery leadremoval include suspected digestive tract perforation [1],patients with high risk of tamponade during operation andwith atypical location of the perforating lead [3, 6, 9-11, 13,15, 18]. In most of these cases, a new pacemaker wasimplanted, placing the lead tip in a different location thanbefore (that is in the RVOT if the tip had been placed inthe apex, and vice versa). In the case of open surgery,epicardial leads have been used [1, 6]. In one case, a newpacemaker was not implanted at the patient’s demand[10]. There has also been one case in which the perforatingatrial lead was not removed, and the DDD mode wasswitched to the VVI mode, due to the high operation risk[14]. Hirschl et al. indicate that removing delayedasymptomatic lead perforations with normal pacemakerfunction is disputable [4]. In the postoperative period,echocardiographic monitoring is necessary, as there havebeen cases of cardiac tamponade described [1].The case presented above is atypical considering theliterature, mainly due to its very late presentation (3 yearsafter implantation). It is worth underlining that there wasno evident cause of the perforation (e.g. trauma) in theanamnesis. It also seems as if we have captured themoment of the full lead perforation with effusionformation. During the observation, we noted slightregression in the effusion quantity and its organisation.Another rare symptom was normal pacemakerelectrophysiological parameters.ConclusionsLead perforation of the heart remains a rare, butgenuine threat. Sometimes it creates a real diagnosticpuzzle and has confusing clinical presentation. Normalpacemaker electrophysiological function does not excludelead perforation. Optimal treatment for such a conditionseems to be percutaneous extraction of the perforatinglead with cardiosurgical backup, though this opinion isinconsistent with the HRS expert consensus.References1. Laborderie J, Barandon L, Ploux S, et al. Management of subacuteand delayed right ventricular perforation with a pacing orimplantable cardioverter-defibrillator lead. Am J Cardiol 2008; 102: 1352-5. 2. Khan M, Joseph G, Khaykin Y, et al. Delayed lead perforation:a disturbing trend. PACE 2005; 28: 251-3.3. Fisher JD, Fox M, Kim SG, et al. Asymptomatic anterior perforationof an ICD lead into subcutaneous tissues. PACE 2008; 31: 7-9. 4. Hirschl DA, Jain VR, Spindola-Franco H, et al. Prevalence andcharacterization of asymptomatic pacemaker and ICD leadperforation on CT. PACE 2007; 30: 28-32.5. Lau EW, Shannon HJ, McKavanagh P. Delayed cardiac perforationby defibrillator lead placed in the right ventricular outflow tractresulting in massive pericardial effusion. PACE 2008; 31: 1646-1649. 6. Krivan L, Kozak M, Vlasinova J, et al. Right ventricular perforationwith an ICD defibrillation lead managed by surgical revision andepicardial leads-case reports. PACE 2008; 31: 3-6.7. Tavernier R, Duytschaever M, Dossche K, et al. Subacuteimplantable cardioverter defibrillator lead perforation: a potentiallylife-threatening event. Europace 2009; 7: 966-7. Figure 3. TTE after the removal procedure: visibleliquid in the pericardium up to 8 mm behind theposterior wall and up to 9 mm before the anteriorwall (arrows)Ao – aorta, LA – left atrium, LV – left ventricle, RV – right ventricleKardiologia Polska 2010; 68: 3361Delayed perforation of the right ventricle as a complication of permanent heart stimulation 8. Satpathy R, Hee T, Esterbrooks D, et al. Delayed defibrillator leadperforation: an increasing phenomenon. PACE 2008; 31: 10-2.9. Haq SA, Heitner JF, Lee L, et al. Late presentation of a leadperforation as a complication of permanent pacemaker insertion.Angiology 2008; 59: 619-21.10. Sassone B, Gabrieli L, Boggian G, et al. Management of traumaticimplantable cardioverter defibrillator lead perforation of the rightventricle after car accident: a case report. Europace 2009; 7: 961-2.11. Tziakas D, Alexoudis A, Konstantinou F, et al. A rare case of lateright ventricular perforation by a passive-fixation permanentpacemaker lead. Europace 2009; 7: 968-9. 12. Akyol A, Aydin A, Erdinler I, et al. Late perforation of the heart,pericardium and diaphragm by an active-fixation ventricular lead.PACE 2005; 28: 350-1.13. Sanoussi A, Nakadi BE, Lardinois I, et al. Late right ventricularperforation after permanent pacemaker implantation: how far canthe lead go? PACE 2005; 28: 723-5. 14. Henrikson CA, Leng CT, Yuh DD, et al. Computed tomography toassess possible cardiac lead perforation. PACE 2006; 29: 509-11.15. Selcuk H, Selcuk MT, Maden O, et al. Uncomplicated heart andlung perforation by a displaced ventricular pacemaker lead: a casereport. PACE 2006; 29: 429-30. 16. Greenberg S, Lawton J, Chen J. Right ventricular lead perforationpresenting as left chest wall muscle stimulation. Circulation 2005;111: e451-2. 17.  Wilkoff BL, Love CJ, Byrd CL, et al. Transvenous lead extraction:Heart Rhythm Society expert consensus on facilities, training,indications, and patient management: This document wasendorsed by the American Heart Association (AHA). Heart Rhythm2009; 6: 1085-104.18. Celik T, Kose S, Bugan B, et al. Hiccup as a result of late leadperforation: report of two cases and review of the literature.Europace 2009; 7: 963-5. 19. Lopes LR, Brandao L, Carrageta M. Single-step transvenousextraction of a passive fixation lead with delayed perforation ofthe right ventricle. Europace 2009; 8: 672.    

Późna perforacja prawej komory jako powikłanie stałej stymulacji serca - czy przestrzeganie wytycznych jest zawsze właściwym wyborem? Postępowanie niestandardowe : opis przypadku i przegląd piśmiennictwa

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Późna perforacja prawej komory jako powikłanie stałej stymulacji serca - czy przestrzeganie wytycznych jest zawsze właściwym wyborem? Postępowanie niestandardowe : opis przypadku i przegląd piśmiennictwa

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