A 61-Year-Old Man with Perforation of the Left Ventricle and Pericardium 3 Days After Insertion of a Cardiac Pacemaker Lead

Introduction

The use of implantable cardiac devices, encompassing permanent pacemakers, has become a customary medical procedure, which has a low incidence of reported complications [1]. Serious complications include battery dysfunction, implant site infection, and electrode lead breakage/displacement [2]. Cardiac perforation is a rare complication after pacemaker and implantable cardioverter-defibrillator implantation, with incidence rates ranging from 0% to 6.38% [3]. Perforation can occur acutely at the time of lead insertion or can be delayed for days, months, or even years. Symptoms vary widely in patients with lead perforation, and some patients can be underdiagnosed due to mild and asymptomatic symptoms [4]. The right ventricle is the most common site of cardiac perforation, primarily because this is a common site for ventricular leads, and because the myocardial wall is thinner here than at other common pacing sites, such as the interventricular septum and the right ventricular outflow tract [5,6]. In rare cases, the perforation crosses the interventricular septum and causes a left ventricular perforation [7].

This report describes 61-year-old man with perforation of the left ventricle and pericardium diagnosed at 3 days after insertion of a cardiac pacemaker lead.

Case Report

A 61-year-old male patient underwent permanent pacemaker implantation for second degree type II sinoatrial block. He was previously received a diagnosis of coronary artery disease and hypertension and underwent coronary stent implantation 6 months earlier. On the third day after pacemaker implantation, the patient developed persistent chest pain and came to our hospital. An electrocardiogram showed sinus rhythm (Figure 1), chest X-ray showed the right ventricular lead exceeding the left heart edge (Figure 2A), and chest computed tomography (CT) showed the pacing lead penetrating the left ventricle and pericardium (Figure 2B–2D). After the diagnosis was made, the patient underwent surgery. Intraoperative fluoroscopy was used to locate the pacing lead at the point of entry into the left ventricle (Figure 3A), a 4-cm skin incision was made at the appropriate thoracic site, and the subcutaneous tissue was incised to enter the left chest. The pacing lead penetrated the pericardium into the thoracic cavity for approximately 5 cm (Figure 3B), and the pericardium was incised to see that the lead was approximately 5 mm from the left anterior descending branch, with a small amount of bloody fluid in the pericardial cavity. Using 4-0 Prolene with a felt spacer, the purse-string was sutured to the left ventricular surface, and the suture was passed through the tip of the pacing lead (Figure 3C). The lead was slowly withdrawn into the ventricle and the purse-string was tightened and knotted to ensure that the tip of the lead was secured to the left ventricular myocardium. The pacemaker was tested for good function, and the lead was seen to be in a satisfactory position on fluoroscopy (Figure 3D). Postoperative chest CT showed that the position of the lead was fixed within the left ventricular myocardium, and the patient was discharged on day 3 after the procedure, without complications.

Discussion

Physicians should be familiar with the diagnosis and treatment of complications associated with pacemaker implantation, which include displacement of atrial and/or ventricular leads, necessitating repositioning; infection; pneumothorax requiring chest tube placement or prolonged hospitalization; hemothorax; cardiac tamponade; acute myocardial infarction; and death [8]. The incidence of cardiac perforation resulting from pacemaker implantation is relatively low but can potentially be life-threatening. In such cases, the leads can perforate the outside of the pericardium, increasing the risk of vascular or pulmonary injury [4]. The classification of perforation is dependent on the time of symptom onset, and thus can be categorized as acute (presenting within 24 h), subacute (within 30 days), or chronic (more than 30 days after implantation) [5]. The clinical presentation of cardiac perforation is highly variable and can include chest pain, dyspnea, hypotension, and shock. The most common presenting symptom is chest pain, which accounts for 46% of cases [9]. It can manifest in a variety of timeframes, but is most frequently observed in subacute episodes. Asymptomatic presentations are most prevalent in chronic cohorts and are frequently overlooked or misdiagnosed [10]. The diagnosis of cardiac perforation should be considered in all patients treated with pacemaker or combination devices, regardless of the duration of implantation. Our patient presented with a subacute episode of chest pain, which was likely caused by irritation of the chest wall and lung tissue by the lead tip.

It has been demonstrated that the prevalence of cardiac perforation can be elevated in instances in which active fixed leads are used [7]. The use of exposed and small-diameter lead tips has been identified as a risk factor for cardiac perforation. Similarly, excessive twisting of active fixed leads has been linked to an increased likelihood of this complication. The forced advancement of the myocardial wall or overextension of the fixation helix exerts additional stress on the myocardium [11]. Our patient was implanted with a permanent pacemaker with a helical lead, and the helical tip may have been overextended.

The diagnosis of perforation is primarily based on imaging findings, rather than on clinical features. In patients with suspected perforation, chest X-rays are useful for determining whether the location of the leads is anomalous, particularly when compared with the postoperative view [12]. Echocardiography is a straightforward, non-invasive examination that enables the assessment of electrode positioning and the detection of pacemaker lead tips within the pericardium. It is also a valuable tool for diagnosing pericardial effusion and pericardial tamponade, which are significant complications associated with lead perforation [13]. However, both diagnostic methods have inherent limitations, and the precise location of the pacemaker lead may not be accurately determined. A chest CT scan is considered a valuable diagnostic tool for identifying pacemaker lead perforation, as it can accurately demonstrate pacemaker lead displacement [14]. Recent studies have demonstrated that CT imaging has a 98.1% accuracy in diagnosing lead perforation, which is a superior diagnostic performance, compared with that of chest radiography (73.1%) and echocardiography (82.7%) [15]. However, the presence of artefacts from the exposed metal portion of the lead can result in an inability to accurately locate the lead, which is detrimental to the identification of minor perforations. Therefore, it is necessary to select an appropriate window for detection.

The optimal treatment for patients with perforations remains unclear. In accordance with the 2017 Heart Rhythm Society expert consensus statement, if lead perforation results in pain, bleeding, or other complications, lead removal will constitute an essential component of the patient’s comprehensive treatment plan [16]. Although it is less invasive, this approach can result in fatal complications, including pericardial tamponade or hemorrhagic shock. A small incision was made through the left intercostal space, allowing for the stable fixation of the pacing lead within the left ventricular myocardium, while avoiding the potential complications of pericardial tamponade and additional surgical incisions that can be caused by removing the lead. This approach is less invasive than open heart surgery, thereby avoiding the potential complications of sternotomy and prolonged hospitalization.

Conclusions

This study reports the case of a patient who presented with a left ventricular and pericardium perforation 3 days after pacemaker implantation and underwent a successful, minimally invasive repair of the perforation. This clinical case underscores the necessity for screening for perforation in patients treated with cardiac implantable electronic devices prior to discharge.