656 Cough, a rare and not well recognized symptom of lead perforation

Abstract Aims Along with relevant progress in technology, pacemaker implantation is continuously improving its safety and efficacy in treating patients with bradyarrhythmias. Despite this, this procedure has several complications, including haematoma, pneumothorax, lead dislodgement, infection, lead perforation, and tamponade. Methods and results A 64-year-old woman underwent loop recorder implantation, after recurrent loss of consciousness, in order to assess arrhythmic causes of syncope. Two weeks later, an episode of paroxysmal complete AV block, conditioning a pause of 3 s, was recorded. Thus, the patient was scheduled for urgent dual-chamber pacemaker implantation. No complication apparently occurred during the procedure. An active fixation ventricular lead was positioned in right ventricular septal apex while passive fixation atrium lead in the right appendage. Soon after implantation the patient started to suffer by non-productive cough, clearly related to ventricular stimulation, either in DDD or in VVI pacing modality. During spontaneous ventricular activation (RBBB) no symptoms occurred. Transthoracic echocardiography, performed the day after implantation, revealed a small pericardial effusion (diastolic diameter < 10 mm) along the apical segments, near the tip of the right ventricular lead. Suspicion of right ventricular lead perforation arised. The patient underwent urgent contrast chest CT confirming pericardial effusion, and showing an intramyocardium placement of the right ventricular apical lead. No active bleeding in pericardium was observed. Due to persistence of symptoms, we decided to perform right ventricular lead repositioning in right middle septum, with pericardiocentesis back-up promptly available. Post-procedure, palpitation, and cough abruptly disappeared. After 3 months follow-up, no significant symptoms were reported and pericardial effusion gradually disappeared. Conclusions We describe a singular case of cough, as atypical symptom immediately after pacemaker implantation. Pericardial effusion and contrast-CT showing intra-myocardial position of the tip guided our suspicion to a possible right ventricular lead microperforation. Although right ventricular lead parameters were completely normal this findings didn’t exclude RV perforation. The lead perforation is known as a rare complication of device implantation. Typical symptoms of RV lead perforation are chest pain and hypotension. The patient described in our case showed a haemodynamically stable pericardial effusion accompanied by non-productive cough, clearly time-related to RV stimulation. In literature, there is only another similar case report. The cough is a rare and not well recognized symptom of lead perforation. Early diagnosis of RV perforation allows to perform urgently and safely (pericardiocentesis back-up) lead replacement/repositioning. Echocardiography and contrast-CT could be useful in order to assess a possible pericardial effusion or intramyocardial/pericardial position of RV lead tip.

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Late unexpected complete fracture of a right ventricular lead still capturing the myocardium

BMJ Case Reports ◽

10.1136/bcr-2021-244087 ◽

2021 ◽

Vol 14 (8) ◽

pp. e244087

Author(s):

Teona Serafimova ◽

Georgia May Connolly ◽

Eva Sammut ◽

Ihab Diab

Keyword(s):

Right Ventricular ◽

Late Complication ◽

Pacemaker Implantation ◽

Complete Separation ◽

Lead Fracture ◽

Ventricular Lead ◽

Pacing Lead ◽

Chest X Ray ◽

Rv Pacing ◽

The Right

A 72-year-old man presented for routine dual chamber pacemaker interrogation 13 years following insertion for sick sinus syndrome. Increased noise, impedance and threshold of the right ventricular (RV) lead were identified. RV capture was maintained with an overall RV pacing burden of 47%. A routine generator replacement was scheduled alongside RV lead replacement. Fluoroscopy at the start of the procedure revealed an unexpected striking fracture of the RV pacing lead with complete separation of the proximal and distal portions within the RV. The patient was asymptomatic and described no predisposing factors. He underwent implantation of a new ventricular lead and generator and has remained well. This case demonstrates clear RV lead fracture as a late complication of pacemaker implantation despite maintained capture. This emphasises the need for a chest X-ray when a change in device parameters is noted at device interrogation even in the absence of symptoms.

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Left ventricular free wall perforation by a right ventricular pacemaker lead: a case report

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytab125 ◽

2021 ◽

Vol 5 (3) ◽

Author(s):

Natsuko Satomi ◽

Kenji Enta ◽

Masato Otsuka ◽

Yasuhiro Ishii ◽

Ryota Asano ◽

...

Keyword(s):

Right Ventricular ◽

Rare Complication ◽

Pacemaker Implantation ◽

Left Ventricular ◽

Free Wall ◽

Off Pump ◽

Lead Fracture ◽

Lead Perforation ◽

Temporary Pacemaker ◽

Wall Perforation

Abstract Background Lead perforation is one of the major complications of pacemaker implantation, but cases of right ventricular (RV) lead perforation through the septum and left ventricle are rarely reported. We described a rare case of left ventricular (LV) free wall perforation by an RV lead and the management of this complication. Case summary An 84-year-old man was admitted with a dual-chamber pacemaker due to pacing failure caused by an RV lead fracture. New lead implantation was performed on the next day, but pacing failure occurred again on the second post-operative day (POD). We found the lead perforation on the fluoroscopy during temporary pacemaker insertion. Computed tomography scan and transthoracic echocardiogram showed that the added lead perforated through both the septum and LV free wall. A new lead was inserted on the fourth POD, and an off-pump open chest surgery for extraction of the penetrating lead was performed uneventfully on the 20th POD. Discussion We considered that some features of the lead (SelectSecure 3830-69, Medtronic) may be related to this complication, as the lead was very thin, had a non-retractable bare screw and was inserted with a dedicated delivery catheter. We have to be careful when performing implantation of this kind of lead to avoid such a rare complication.

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Right ventricular perforation, pneumothorax, and a pneumatocele by a pacemaker lead: a case report

JA Clinical Reports ◽

10.1186/s40981-021-00470-8 ◽

2021 ◽

Vol 7 (1) ◽

Author(s):

Shihoko Iwata ◽

Ayana Hirose ◽

Ikue Furui ◽

Takako Matsumoto ◽

Makoto Ozaki ◽

...

Keyword(s):

Right Ventricular ◽

Cystic Lesion ◽

Lung Resection ◽

Pacemaker Implantation ◽

Lead Extraction ◽

Pacemaker Lead ◽

Excellent Outcome ◽

Ventricular Lead ◽

Life Threatening ◽

The Right

Abstract Background Perforation of the right ventricle by a pacemaker lead is a rare and potentially life-threatening complication. We present a patient who developed right ventricular perforation, pneumothorax, and a cyst and underwent partial lung resection. Case presentation A 94-year-old woman was diagnosed with sick sinus syndrome and underwent a dual-chamber permanent pacemaker implantation. The next day, pacing failed and chest radiography showed that the right ventricular lead was outside the cardiac silhouette. Computed tomography revealed that the lead had perforated the right ventricular apex, causing a left-sided pneumothorax and a cystic lesion at the site of pulmonary injury by the pacemaker lead. The patient underwent lung resection and a right ventricular lead extraction. Pathological analysis revealed the cystic lesion to be an acute pneumatocele. Conclusions Pneumothorax and pneumatocele associated with right ventricular pacemaker lead perforation is extremely rare. In our case, a radical surgical intervention provided an excellent outcome.

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Delayed presentation of right ventricular lead perforation following defibrillator implantation: a case report

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytz121 ◽

2019 ◽

Vol 3 (3) ◽

Author(s):

Daniel Ahlert ◽

Andrew R J Mitchell

Keyword(s):

Right Ventricular ◽

Rare Complication ◽

Initial Assessment ◽

Delayed Presentation ◽

Cardiac Device ◽

Device Implantation ◽

Case Summary ◽

Lead Perforation ◽

Ventricular Lead ◽

Important Diagnostic Tool

Abstract Background Perforation of a device lead through the myocardium is a recognized complication of cardiac device implantation. The associated morbidity and mortality are significant, even though it is a relatively rare complication. Therefore, it is vital for acute clinicians to be aware of the diagnosis and subsequent management of myocardial perforation. Case summary We present the case of a 48-year-old woman who presented to the emergency department 1 month following implantable cardioverter-defibrillator implantation with chest and shoulder pain. Initial assessment revealed bilateral pleural effusions and anaemia. Computerized tomography of her chest and abdomen demonstrated a pericardial effusion, but it was transthoracic echocardiography that confirmed the diagnosis of right ventricular perforation. Urgent system revision was undertaken. Discussion This case highlights the importance of clinical suspicion and the use of diagnostic echocardiography as an important diagnostic tool in symptomatic patient’s post-cardiac device implantation.

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Uncomplicated Right Ventricular Lead Perforation Diagnosed with Computed Tomography after Permanent Pacemaker Implantation

Clinical Cardiology ◽

10.1002/clc.20081 ◽

2009 ◽

Vol 32 (7) ◽

pp. E54-E54 ◽

Cited By ~ 1

Author(s):

Yong-Seok Kim ◽

Seil Oh ◽

Kyung Woo Park ◽

Kwang Ree Cho ◽

Yun-Shik Choi

Keyword(s):

Computed Tomography ◽

Right Ventricular ◽

Pacemaker Implantation ◽

Permanent Pacemaker ◽

Permanent Pacemaker Implantation ◽

Lead Perforation ◽

Ventricular Lead

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Surgical Repair of Subacute Right Ventricular Perforation after Pacemaker Implantation

Case Reports in Cardiology ◽

10.1155/2017/3242891 ◽

2017 ◽

Vol 2017 ◽

pp. 1-3 ◽

Cited By ~ 2

Author(s):

Takeshi Oda ◽

Takanori Kono ◽

Keiichi Akaiwa ◽

Yasushi Takahara ◽

Chie Yasuoka ◽

...

Keyword(s):

Right Ventricle ◽

Right Ventricular ◽

Rare Complication ◽

Pacemaker Implantation ◽

Median Sternotomy ◽

Axillary Vein ◽

Pericardial Cavity ◽

Temporary Pacing ◽

Pacing Lead ◽

The Right

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.

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INFLUENCE OF RIGHT VENTRICULAR LEAD IMPLANTATION SITE CHOICE ON PACING EFFICIENCY

International Medical Journal ◽

10.37436/2308-5274-2019-4-3 ◽

2020 ◽

pp. 13-17

Author(s):

Dmitrii Aleksandrovich Lopyn ◽

Stanislav Valerevich Rybchynskyi ◽

Dmitrii Evgenevich Volkov

Keyword(s):

Heart Failure ◽

Right Ventricular ◽

Longitudinal Strain ◽

Treatment Options ◽

Global Longitudinal Strain ◽

Optimal Method ◽

Cardiac Stimulation ◽

Ventricular Lead ◽

The Right ◽

Stimulation Of

Currently the electrophysiological treatment options have been considered to be the most effective for many patients with arrhythmogenic cardiomyopathies, as well as in those with arrhythmias on the background of heart failure. Currently, the dependence of efficiency of the pacemakers on the location of the electrodes has been proven. In order to study the effect of a myocardial dysynchrony on the effectiveness of pacing depending on the location of the right ventricular electrode, an investigation has been performed. This study comprised the patients with a complete atrioventricular block, preserved ejection fraction of the left ventricle (more than 50 %), with no history of myocardial infarction, who were implanted with the two−chamber pacemaker. It has been established that the best results were achieved with a stimulation of the middle and lower septal zone of the right ventricle, the worst ones were obtained with a stimulation of its apex. It has been found that the dynamics of the magnitude of segmental strains and a global longitudinal strain coincided with the dynamics of other parameters of the pacemaker effectiveness, which indicated the pathogenetic value of myocardial dysynchrony in the progression of heart failure after implantation of the pacemaker. Therefore it could be concluded that the studying of myocardial mobility by determining a longitudinal strain for assessing the functional state of the myocardium and the effectiveness of pacing is highly advisable. It is emphasized that the use of the latest strains−dependent techniques for cardiac performance evaluation in the patients with bradyarrhythmia have a great potential to predict the development of chronic heart failure and to choose the optimal method of physiological stimulation of the heart. Key words: right ventricular lead, cardiac stimulation, myocardial dyssynchrony.

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