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Year : 2021  |  Volume : 9  |  Issue : 1  |  Page : 35-39

Delayed perforation of the right ventricle by pacemaker/automated implantable cardioverter-defibrillator lead: A single-center experience

Department of Cardiovascular and Thoracic Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Submission29-Sep-2020
Date of Decision29-Sep-2020
Date of Acceptance16-Dec-2020
Date of Web Publication30-Mar-2021

Correspondence Address:
Sushil K Singh
Department of Cardiovascular and Thoracic Surgery, King George's Medical University, Lucknow - 226 003, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/heartindia.heartindia_43_20

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Introduction: Cardiac perforation by pacemaker/automatic implantable cardioverter-defibrillator (AICD) lead can be a life-threatening emergency. Delayed cardiac perforation by pacemaker/AICD lead is defined as perforation occurring after a period of 1 month following pacemaker/AICD insertion. Delayed perforation is often difficult to identify at first and needs active intervention to prevent complications and death.
Materials and Methods: Patients presenting with and operated upon for delayed cardiac perforation following pacemaker/AICD insertion were included in this study. The study was conducted between April 2019 and April 2020.
Results: Three patients reported with delayed cardiac perforation after pacemaker insertion. All patients had syncopal episodes, and detection could be easily done using chest X-ray and trans-thoracic echocardiography (TTE). Two patients had active fixation leads used for anchoring the lead in the right ventricle (RV). Two patients were female, while one was a male, and all had perforation through the RV apex. Lead reposition was done in two cases, thereby preventing the need for placing additional leads, while a new lead was required in the third case.
Conclusion: Early identification of cardiac perforation can be done easily with chest X-ray and TTE, but a high index of suspicion should be kept in mind. Surgical or fluoroscopic intervention may be planned depending on the available expertise and patient condition.

Keywords: Active fixation pacemaker lead, delayed cardiac perforation, pacemaker complications

How to cite this article:
Kumar S, Tewarson V, Hakim MZ, Kumar S, Singh SK. Delayed perforation of the right ventricle by pacemaker/automated implantable cardioverter-defibrillator lead: A single-center experience. Heart India 2021;9:35-9

How to cite this URL:
Kumar S, Tewarson V, Hakim MZ, Kumar S, Singh SK. Delayed perforation of the right ventricle by pacemaker/automated implantable cardioverter-defibrillator lead: A single-center experience. Heart India [serial online] 2021 [cited 2021 Oct 27];9:35-9. Available from: https://www.heartindia.net/text.asp?2021/9/1/35/312484

  Introduction Top

The perforation of right ventricle (RV) following permanent pacemaker implantation (PPI)/automatic implantable cardioverter-defibrillator (AICD) is rare, with an incidence of 0.1%–0.8%.[1] Acute perforation of the RV is defined as occurring within 24 h of lead insertion. It can be potentially fatal, causing hemopericardium, cardiac tamponade, and ultimately death.[2] Delayed perforation of the RV by pacemaker lead is defined as occurring after at least 1 month from pacemaker implantation. Delayed perforation is associated with significant morbidity and mortality, due to difficulties and delay in identification. Patients can present variably with none to minimal effusion or even impending tamponade.[3],[4]

  Materials and Methods Top

The study was conducted between April 2019 and April 2020 in the department of cardiovascular and thoracic surgery, in three patients who had presented with cardiac perforation due to pacemaker lead/AICD. The study conforms to the widely accepted ethical principles guiding human research (such as the Declaration of Helsinki). Because this was a series of three rare cases, where standard surgery was done, ethical approval was not sought. The clinical details of patients are listed in [Table 1]. The summary of the cases is as follows:
Table 1: Clinical details of the patients

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Case 1

A 65-year-old male patient reported to the cardiology emergency department with a complaint of twitching sensation in the left side of the abdomen and lower chest and a few episodes of syncope. The patient had a history of PPI done 2 months back for symptomatic 2:1 atrio-ventricular (AV) block. The patient was evaluated with electrocardiogram (ECG), chest X-ray, and trans-thoracic echocardiography (TTE), which demonstrated dislodged pacemaker lead, lying in the mediastinum stimulating the diaphragm, and ECG demonstrated 2:1 AV block [Figure 1]. The patient was managed initially by insertion of a temporary external pacemaker and then taken for surgery. During surgery, the pacemaker lead was seen perforating the RV apex and lying in the thoracic cavity, touching the diaphragm [Figure 2]. The pacemaker lead was retrieved from the right sub-clavicular pocket. The perforation site was secured with polypropylene sutures. A new set of epicardial pacemaker was inserted and tunneled in the intramuscular plane and connected with the generator in the sub-clavicular pocket. Follow-up ECG was normal. The patient improved symptomatically and has been under regular follow-up.
Figure 1: Case 1 – Chest X-ray demonstrating pacemaker lead lying on the left hemidiaphragm and electrocardiogram demonstrating 2:1 heart block after pacemaker placement

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Figure 2: Case 1 – Intraoperative photograph demonstrating the pacemaker lead perforating the right ventricular apex

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Case 2

A 60-year-old female, a known case of chronic pancreatitis and dilated cardiomyopathy with 25% ejection fraction and a history of anterior wall myocardial infarction with complete heart block, presented to the cardiology emergency department. AICD with active fixation lead was inserted 2 months back in the cardiology department, and the patient had returned for follow-up with multiple episodes of syncope. Bradycardia along with reduction in sensing threshold with elevated capture threshold and increased impedance was noted [Figure 3]. The patient was evaluated with TTE that demonstrated RV perforation with displaced lead in the pericardial cavity. Temporary external pacemaker was placed, and the patient was taken up for surgery. During surgery, active fixation lead was noted lying in the pericardial cavity after perforating the RV apex [Figure 3]. A purse string was placed using polypropylene suture at the RV apex and the lead was pushed back into the RV. The lead was fixed by snugly tying the purse string over the lead in the RV wall. Follow-up ECG was normal, and the patient is regularly visiting the follow-up clinic since then with no fresh complaints.
Figure 3: Case 2 – Increased impedance, reduced sensing threshold, and elevated capture threshold with bradycardia on presentation, and intraoperative photograph demonstrating active fixation lead perforating the right ventricular apex

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Case 3

A 60-year-old female, a known case of asthma with complete heart block, reported with the complaint of syncope 3 months after placement of PPI. The patient was evaluated with ECG, chest X-ray, and TTE. ECG demonstrated complete heart block. TTE demonstrated PPI lead perforation of RV and migration of the lead through the diaphragm into the abdomen. The patient was placed on temporary external pacemaker and taken up for surgery. During surgery, active fixation-type pacing lead was noted after retrieval from the abdomen. A polypropylene suture purse string was placed around the perforating wire at the RV apex. The lead was pushed back into the RV and the purse string was tied, ensuring that the tip of the pacemaker lead was held snugly in the RV wall [Figure 4]. Defect in the diaphragm was closed with polypropylene sutures. The patient improved symptomatically on follow-up, and ECG was also normal.
Figure 4: Case 3 – Intraoperative photograph demonstrating purse string suture over the right ventricular wall, encircling the active fixation lead

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  Results Top

Of the three patients presenting with delayed perforation, two were female, while one was male. All the patients were in their 60s. Surgical approach was different in the first patient, who was operated using a left anterolateral thoracotomy. The other two patients were operated using median sternotomy. Pacemaker leads were replaced in the initial case, whereas the original leads were retained in the subsequent two cases. There was negligible blood loss, no need for cardiopulmonary bypass, and no perioperative arrest. [Table 2] describes the postoperative data; all patients were extubated early within 2 h. Intensive care unit stay was also short in all cases. No patient required blood or blood product transfusions. The postoperative recovery in all cases was unremarkable, and patients were discharged as per protocol. All patients have been in regular follow-up since then and have not experienced any new symptoms.
Table 2: Postoperative data of patients

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  Discussion Top

Perforation of RV free wall can often be silent. The RV apex has been cited as the most frequent site due to its thin wall.[5] The most common factors predisposing to cardiac perforation include age, use of active fixation leads, body mass index <20, female gender, use of steroids, and anticoagulation.[6],[7],[8] Although active leads are mostly incriminated, perforation by passive leads has also been reported. Aside from lead characteristics, pacemaker fixation technique, such as over-torquing of the active fixation mechanism or excessive coiling and increased tension in an implanted lead, may act as potential causes for delayed perforation.[3],[9]

Findings of cardiac perforation due to pacemaker/AICD leads include chest pain, pericardial rub, dyspnea, syncope, capture failure, inappropriate AICD shocks, and twitches resulting in muscle/diaphragmatic stimulation. Pain abdomen, effusion, and even hiccups as a result of phrenic nerve stimulation have also been noted.[7] Hemodynamic instability needs to be carefully evaluated as hypotension may indicate cardiac tamponade that may need immediate surgical intervention. It is important to note that many patients might even be asymptomatic or have vague nonspecific symptoms such as dizziness or fatigue.[10],[11]

Diagnosis of ventricular perforation is based on pacing or sensing failure, increased capture threshold, and reduced sensing threshold. Variations noted in the impedance depend on the tissue in which the tip has migrated (air or fluid). Although inappropriate pacemaker function and presence of right bundle branch block may indicate possible perforation, normal function does not exclude its possibility.[3],[11]

The main factor in the diagnosis is visualization of the lead tip, which can be achieved by a simple chest skiagram. Findings include displacement of lead tip beyond the cardiac silhouette up to 2 mm in subtle cases or gross displacement of the lead beyond the normal cardiac shadow into the lungs or abdomen. Pleural effusion especially on the left side is also noticeable.[12] TTE has been used widely as a diagnostic modality for most cases of cardiac perforation and also allows timely detection of pericardial and pleural effusions. Computed tomographic (CT) scans can be useful in cases where the apex is obscured by pleural effusions and TTE is unequivocal. Near or impending perforation can also be detected using CT as the tip may lie close to the epicardium.[2],[12]

Management strategies for cardiac perforation from pacemaker leads depend on the functional status of the pacemaker and the position of the lead tip. Leaving the lead tip if it is retained in the mediastinum and placing additional leads has been suggested to prevent bleeding complications.[13] In hemodynamically stable patients, fluoroscopic removal of pacemaker leads can be done successfully; however, most such cases are done with surgical backup.[14] Surgical removal in emergency is indicated in patients with hemodynamic instability, and use of temporary pacing is helpful in such scenarios. Friable RV wall has been noted in cases that prohibit the use of suture closure, and novel techniques such as tissue adhesives have also been used in these circumstances.[15],[16]

In our series of cases, two were female, one had simple lead, while two had active fixation leads in situ, all had presented with pacemaker dysfunction and perforation through RV apex; successful retrieval of pacing leads was done by open surgery, while patients were stabilized with external pacing. Repositioning of leads into the RV wall was done successfully in two cases and a new lead was required in one case.

  Conclusion Top

Pacemaker lead perforation being a rare condition may present late, require a high level of suspicion, and present with unusual symptoms. Chest X-ray, ECG, and TTE may be adequate to reach diagnosis. Management strategy depends on the hemodynamic status of the patient and the center's expertise in dealing with these cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Ethical approval

As these were routine cardiac surgery cases, the involvement of the Institute Review Board was not performed. Full informed consent was obtained from these patients before surgery for usage of their data.

Authors' contributions

Sarvesh Kumar: Performed literature review and prepared manuscript. Vivek Tewarson: helped with review of literature and manuscript preparation. Mohammad Zeeshan Hakim: Helped with manuscript preparation and collection of data and results. Shobhit Kumar: Helped in data collection. Sushil Kumar SIngh: conceived and designed this work, supervised the manuscript preparation and edited the manuscript prior to submission. All authors have seen the final manuscript and approve it for publication.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Yılmaztepe MA, Taylan G. Subacute presentation of right ventricular perforation due to pacemaker lead. Am J Cardiol 2018;121:e88-9.  Back to cited text no. 1
Khalid M, Murtaza G, Ayub MT, Ramu V, Paul T. Right ventricle perforation post pacemaker insertion complicated with cardiac tamponade. Cureus 2018;10:e2266.  Back to cited text no. 2
Refaat MM, Hashash JG, Shalaby AA. Late perforation by cardiac implantable electronic device leads: Clinical presentation, diagnostic clues, and management. Clin Cardiol 2010;33:466-75.  Back to cited text no. 3
Caiati C, Pollice P, Truncellito L, Lepera ME, Favale S. Minimal cardiac perforation by lead pacemaker complicated with pericardial effusion and impending tamponade: Optimal management with no pericardiocentesis driven by echocardiography. Diagnostics (Basel) 2020;10:191.  Back to cited text no. 4
Akbarzadeh MA, Mollazadeh R, Sefidbakht S, Shahrzad S, Bahrololoumi Bafruee N. Identification and management of right ventricular perforation using pacemaker and cardioverter-defibrillator leads: A case series and mini review. J Arrhythm 2017;33:1-5.  Back to cited text no. 5
Sheikh AS, Ardehali HF, Mazhar S. Right ventricular perforation by a passive-fixation pacemaker lead two weeks after implantation. J Arrhythmia 2014;30:522-4.  Back to cited text no. 6
Akbarzadeh MA, Mollazadeh R, Sefidbakht S, Shahrzad S, Bafruee BN, Archontakis S, et al. Delayed cardiac perforation due to migrating pacemaker lead. J Arrhythmia 2010;33:1-5.  Back to cited text no. 7
Rydlewska A, Małecka B, Zabek A, Klimeczek P, Lelakowski J, Pasowicz M, et al. Delayed perforation of the right ventricle as a complication of permanent cardiac pacing-is following the guidelines always the right choice? Non-standard treatment-A case report and literature review. Kardiol Pol 2010;68:357-61.  Back to cited text no. 8
Tziakas D, Alexoudis A, Konstantinou F, Chalikias G, Stakos D, Bougioukas G. A rare case of late right ventricular perforation by a passive-fixation permanent pacemaker lead. Europace 2009;11:968-9.  Back to cited text no. 9
Macdonald J, Kelly D, Waktare J. Value of the unipolar electrogram in the diagnosis of right ventricular perforation following pacemaker implantation. Heart 2005;91:228.  Back to cited text no. 10
Oh S. Cardiac perforation associated with a pacemaker or ICD lead. In: Modern Pacemakers-Present and Future. Das MR, editor.London: InTech; 2011.  Back to cited text no. 11
Rajkumar CA, Claridge S, Jackson T, Behar J, Johnson J, Sohal M, et al. Diagnosis and management of iatrogenic cardiac perforation caused by pacemaker and defibrillator leads. Europace 2017;19:1031-7.  Back to cited text no. 12
Sanoussi A, El Nakadi B, Lardinois I, De Bruyne Y, Joris M. Late right ventricular perforation after permanent pacemaker implantation: How far can the lead go? Pacing Clin Electrophysiol 2005;28:723-5.  Back to cited text no. 13
Archontakis S, Sideris K, Aggeli K, Gatzoulis K, Demosthenous M, Tolios P, et al. Percutaneous lead extraction and repositioning: An effective and safe therapeutic strategy for early ventricular lead perforation with dislocation both inside and outside the pericardial sac following a cardiac device implantation. J Cardiovasc Electrophysiol 2019;30:299-307.  Back to cited text no. 14
Prestipino F, Nenna A, Casacalenda A, Chello M. Ventricular perforation by pacemaker lead repaired with two hemostatic devices. Int J Surg Case Rep 2014;5:906-8.  Back to cited text no. 15
Lewis KM, Kuntze CE, Gulle H. Control of bleeding in surgical procedures: Critical appraisal of HEMOPATCH (Sealing Hemostat). Med Devices (Auckl) 2016;9:1-10.  Back to cited text no. 16


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]


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