Pacing Lead Perforation on the Right Side of the

S. Serge BAROLD M.D.*, Roland X. STROOBANDT M.D.**, Alfons F. Sinnaeve M.D.*** * Cardiology Division, University of South Florida College of Medicine, Tampa, Florida, USA. ** Department of Cardiology, Arrhythmia Unit, University Ghent, Ghent, Belgium. Technical University Khbo, Department of Electronics, Ostend, Belgium

ABSTRACT

Cardiac perforation is a rare potentially serious and often unrecognized complication of pacemaker lead implantation. In this paper, we present a case with pacing lead perforation on the right side of the heart.

KEYWORDS Pacemaker lead, cardiac perforation, unipolar electrograms

Pacing Elektroduna Bağlı Kalbin Sağ Tarafında Perforasyon

ÖZET

Kardiyak perforasyon, elektrot implantasyonunun çoğunlukla tanınamayan nadir fakat önemli bir kompli- kasyonudur. Bu yazıda, pacing elektroduna bağlı sağ kalp perforasyonu olan bir olgu sunulacaktır.

ANAHTAR KELİMELER Pacemaker elektrodu, kardiyak perforasyon, unipolar elektrogramlar

İLETİŞİM ADRESİ S. Serge BAROLD, M.D. S. Serge Barold MD. 5806 Mariner’s Watch Drive, Tampa FL 33615, USA. Pacing Lead Perforation on the Right Side of the Heart 101

ardiac perforation is a rare potentially se- pe, friction rub, sinus tachycardia, increasing Crious and often unrecognized complicati- ventricular pacing threshold, poor sensing, left on of pacemaker lead implantation. It may oc- diaphragmatic stimulation (though this may al- cur at the time of implantation when it may cau- so occur in the absence of perforation), intercos- se hypotension from . Perfo- tal muscle stimulation, and ration usually does not lead to tamponade if the left hemothorax. Rarely perforation occurs into lead is withdrawn and repositioned because the the left through the ventricular septum. perforation is often self-sealing. Rare complications of RV lead perforation inclu- The reported incidence of symptomatic per- de lead migration into the peritoneal cavity, rib foration after initial implantation is about 1%. perforation and damage to a left internal mam- The true incidence of perforation is not well mary graft to the left anterior descending artery known because it may be subclinical and asym- (with myocardial infarction). Also, the left ante- ptomatic. Indeed CT scans in patients with un- rior descending coronary artery (LAD) runs on complicated pacing show a staggering 5% inci- the epicardial surface of the heart within the in- dence of right ventricular perforation and 10% terventricular groove superficial to the intervent- in the case of atrial leads. Risk factors inclu- ricular septum. From a pacing perspective, the de female sex, increasing age, the use of stiff LAD lies at the junction between the septal and stylets and active-fixation leads. Administrati- anterior walls of the RV outflow tract. Therefore, on of oral steroid within 7 days preceding lead inadvertent lead placement on the anterior wall implantation predisposes to perforation. or at the junction between anterior and septal The clinical presentation of perforation has walls (rather than septal fixation) may endanger changed and occurs later than in the past. The the LAD with the helix of an active-fixation lead use of active-fixation small body diameter leads and cause acute myocardial infarction. and implantable cardioverter-defibrillator leads The paced ECG may show a right bundle may be associated with increased risk for dela- branch pattern if the lead paces the left ventricle yed right ventricular perforation. The late pre- usually from the pericardial space (Figure 1). The sentation is a less recognized complication of de- chest X ray may show the lead beyond the cardi- vice implantation and may create an important ac shadow or a peculiar appearance not seen with diagnostic problem with potentially catastrophic traditional uncomplicated right ventricular apical consequences if unrecognized. The development placement (Figure 2). An echocardiogram and of small-diameter Subacute right ventricular per- CT scan should be performed to document lead foration (several days or weeks after seemingly position. Transesophageal is uncomplicated implantation (usually up to 60 superior to transthoracic echocardiography in de- days after implantation and occasionally much lineating the entire course of a pacing lead. Dif- later) is a rare but serious complication of lead ficulty in visualizing the lead in the right ventric- implantation. Perforation can occasionally pre- le is not rare. The CT scan is particularly helpful sent after several months or a year. when echocardiography is equivocal. Multidetec- After implantation, right ventricular perfora- tor computed tomography is emerging as the ima- tion of the free wall may be recognized by pe- ging modality of choice in diagnosing atrial and ricardial pain, abdominal pain, dyspnea, synco- ventricular lead perforation (Figure 3).

CİLT 7, SAYI 2, Haziran 2009 102 Türk Aritmi, Pacemaker ve Elektrofizyoloji Dergisi

FIGURE 1

ECG showing a right bundle branch block pattern during VVI pacing with lead perforation of the right ventricular free wall. The previous ECG had shown a left bundle branch pattern during pacing. On top the ventricular electrograms show a dominant R wave from the tip (T) and proximal or ring electrode (R) consistent with perforation. A on the right shows a pacemaker sound (PS) consistent with perforation. B = bipolar.

FIGURE 2

Chest X ray showing unusual position of right ventricular FIGURE 3 lead in a patient with lead perforation of the right ventricle documented in Figure 3. CT scan showing perforation of a right ventricular lead

These complications may lead to death if dance and continuous EGM monitoring to con- they are not recognized early. In most patients, firm the diagnosis, with surgical backup sup- the leads can safely be removed percutaneously port and together with TEE monitoring. Simp- in the operating room under fluoroscopic gui- le withdrawal of the lead is successful in 80%

CİLT 7, SAYI 2, Haziran 2009 Pacing Lead Perforation on the Right Side of the Heart 103 of the cases. A stable asymptomatic perforation Recording of an adequate unipolar ventricu- can be left alone if pacing and sensing are satis- lar electrogram from the proximal RV electro- factory. If parameters are unsatisfactory, a stab- de but an atypical one from the distal electro- le asymptomatic perforated lead can be left in de should raise the suspicion of lead perforation place and a new lead implanted. and so does the presence of ST elevation from the proximal electrode and its absence from the Diagnostic Value of the Unipolar distal electrode. In the latter case, perforation Electrogram may be absent if the distal portion of the lead High levels of ST segment elevation (cur- is curled up and the tip points superiorly so that rent of injury) in the unipolar tip electrogram endocardial contact occurs only via the proxi- , greater than 10 mV at the time of implantati- mal electrode. on, were found to predispose to electrode per- foration (Figure 4). With RV perforation the Atrial Leads unipolar EGM may show an upright complex Atrial (like RV) lead perforation can be de- that looks like a standard precordial lead over layed for weeks or much longer. Right atrial le- the lateral chest with disappearence of ST ele- ads may perforate both and pleu- vation. When the lead is gradually withdrawn, ra, resulting in pericarditis, cardiac tamponade, some ventricular ectopy may occur as the lead right–sided pneumothorax (associated with left- passes through the ventricular wall. Then, ob- sided venous access), pneumopericardium (with vious ST elevation (current of injury) occurs or without contralateral pneumothorax),. pneu- (Figure 5). This disappears when endocardi- momediastinum, isolated pneumopericardium al contact is lost. The intracavitary EGM often and rarely aortic laceration. shows a deep S wave followed by gradual re- Successful and safe percutaneous lead with- duction of its amplitude and P waves when the drawal (except for aortic perforation) has been lead lies in the right . reported and should be attempted on in the ope-

FIGURE 4

Unipolar electrogram from the tip of a passive fixation pacemaker lead. The marked ST elevation in relation to the QRS deflection indicates myocardial wedging. Excessive wedging with marked ST elevation resembles a monophasic–like action potential. The S wave disappears because the rapid and massive ST elevation gives the impression of a dominant R wave. Withdrawal of the lead by a few millimeters restores the dominant negativity of the QRS part of the electrogram.

CİLT 7, SAYI 2, Haziran 2009 104 Türk Aritmi, Pacemaker ve Elektrofizyoloji Dergisi

FIGURE 5

Unipolar tip electrogram of a perforated right ventricular lead. The electrogram was recorded continuously during gradual withdrawal of the lead. On the top left, there is a tall R wave and slight ST elevation. Gradual withdrawal of the lead reduces the size of the R wave and an rS pattern appears with prominent ST elevation as the lead traverses the myocardium. In the bottom tracing the lead drops into the right ventricle whereupon the ST elevation disappears and the QRS morphology becomes consistent with an intracavitary recording. rating room under transesophageal echocardi- gic pleuro-pericardial effusion associated with ographic guidance. is popular based on markers of inflammation. It may occur some the belief that a non-surgical approach is more weeks after uncomplicated perforation at the likely to cause bleeding as the wall of the right time of initial implantation. Cardiac tampona- atrium is thin and non-muscular. de is rare. A pericardial window may be requ- Recurrent postcardiac injury syndrome in ired and some workers advocate lead withdra- the absence of perforation (diagnosis by exclu- wal. Indomethacin is useful therapy. This situa- sion) should be considered in patients who, after tion may lead to surgical exploration in the beli- pacemaker lead insertion, develop hemorrha- ef that perforation is present.

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