Pericardial effusion caused by accidently placing a Micra transcatheter pacing system into the coronary sinus

Background Leadless pacemaker has been acknowledged as a promising pacing strategy to prevent pocket and lead-related complications. Although rare, cardiac perforation remains a major safety concern for implantation of Micra transcatheter pacing system (TPS). Case presentation A 83-year-old female with low body mass index (18.9 kg m−2) on dual anti-platelet therapy, was indicated for Micra TPS implantation due to sinus arrest and paroxysmal atrial flutter. The patient developed mild pericardial effusion during the procedure since the delivery catheter was accidentally placed into the coronary sinus for several times. Cardiac perforation with moderate pericardial effusion and pericardial tamponade was detected 2 h post-procedure. The patient was treated with immediately pericardiocentesis and recovered without further invasive therapy. Conclusion Pericardial effusion caused by accidently placing a delivery catheter into the coronary sinus is rare but should be carefully considered in Micra TPS implantation, especially for those with periprocedural anti-platelet therapy.

Subclinical cardiac perforation by cardiac implantable electronic device leads detected by cardiac computed tomography

Background The relationship between the characteristics of cardiac implantable electronic device (CIED) leads and subclinical cardiac perforations remains unclear. This study aimed to evaluate the incidence of subclinical cardiac perforation among various CIED leads using cardiac computed tomography (CT). Methods A total of 271 consecutive patients with 463 CIED leads, who underwent cardiac CT after CIED implantation, were included in this retrospective observational study. Cardiac CT images were reviewed by one radiologist and two cardiologists. Subclinical perforation was defined as traversal of the lead tip past the outer myocardial layer without symptoms and signs related to cardiac perforation. We compared the subclinical cardiac perforation rates of the available lead types. Results A total of 219, 49, and 3 patients had pacemakers, implantable cardioverter-defibrillators, and cardiac resynchronization therapy, respectively. The total subclinical cardiac perforation rate was 5.6%. Subclinical cardiac perforation by screw-in ventricular leads was significantly more frequent than that caused by tined ventricular leads (13.3% vs 3.3%, respectively, p = 0.002). There were no significant differences in the incidence of cardiac perforation between atrial and ventricular leads, screw-in and tined atrial leads, pacing and defibrillator ventricular leads, nor between magnetic resonance (MR)-conditional and MR-unsafe screw-in ventricular leads. Screw-in ventricular leads were significantly associated with subclinical cardiac perforation [odds ratio, 4.554; 95% confidence interval, 1.587–13.065, p = 0.005]. There was no case subclinical cardiac perforation by septal ventricular leads. Conclusions Subclinical cardiac perforation by screw-in ventricular leads is not rare. Septal pacing may be helpful in avoiding cardiac perforation.

Transvenous lead revision for cardiac perforation: a single centre experience

Funding Acknowledgements Type of funding sources: None. Background Cardiac perforation is an uncommon but life-threatening complication of cardiac implantable electronic device (CIED) implantation. Management strategy commonly relies on diagnostic Computed Tomography (CT) imaging and cardiac surgery. Emerging evidence has indicated a diversion from this approach. Transvenous culprit lead revision has been shown to be safe and efficacious in limited series. We sought to evaluate the outcomes of transvenous lead revision in patients with cardiac perforation. Method Data was collected retrospectively of patients admitted to a single tertiary centre with CIED-related cardiac perforation between December 2013 – October 2019. Transvenous lead revision was performed as standard with cardiac surgery on standby. Patient demographics, use of CT imaging, method of removal and 30-day outcomes were recorded. Results Of the 46 recorded CIED-related cardiac perforations, the majority occurred in female patients (63%) and hypertensives (61%), whilst a proportion had cancer (20%) and ischaemic heart disease (30%). The culprit in most cases was a standard pacing lead (92%) of an active fixation (98%) in the right ventricle (80%) positioned at the ventricular apex (65%). The median time to presentation from implant was 14 days [IQR 4-50 days] with chest pain (44%); abnormal pacing indices was highly prevalent (95%) whilst a pericardial effusion was noted in the majority of cases (57%). CT scanning was performed in 19 cases (41%) for various indications but deemed essential in only 4, all of which had non-diagnostic pacing indices and imaging. Chest X-ray (CXR) found clear perforation, lead displacement or pleural effusion in 74% of cases, whilst an echocardiogram found these in 64% of cases. The culprit lead was replaced in the majority of cases (87%) under local anaesthesia (76%) with surgical backup. The median hospital stay was 7 days [IQR 3-10 days] with zero procedural and 30-day mortality. Conclusion Transvenous lead revision for CIED-related cardiac perforation is safe and efficacious. CT modality for diagnostic purposes is useful in providing incremental value in a minority of cases; patients with non-diagnostic pacing parameters and non-CT imaging benefit most from this.