Early Detection of Perforation of the Right Ventricle by a Permanent Pacemaker Lead

Hye Kyung Park, MD, Hyo Seung Ahn, MD, Ban Suck Lee, MD, Hye Jin Won, MD, Young Sup Byun, MD, Choong Won Goh, MD, Byung Ok Kim, MD, Kun Joo Rhee, MD and Byoung Kwon Lee, MD Division of Cardiology, Department of Internal Medicine, Sanggye Paik Hospital, Inje University Medical College, Seoul, Korea

ABSTRACT

Ventricular perforation is a rare complication of permanent cardiac pacemaker implantation. We report here on a 68-year-old woman with a dual chamber permanent pacemaker that had been implanted one month earlier, and she suffered cardiac perforation from the pacemaker lead. Frequent follow-up via12-lead surface electrocardiography and chest radiography and the proper work-up for pacemaker implantation are needed for detecting rare complications after pacemaker implantation. (Korean Circulation J 2007;37:453-457)

KEY WORDS：Cardiac pacemaker；Complications.

Introduction p wave and the longest pause was 3.45 sec(Fig. 1A, B). Therefore, we diagnosed her with sick sinus syndrome Myocardial perforation is a rare complication follo- and she underwent implantation of a dual chamber per- wing pacemaker implantation with using contemporary manent pacemaker(Medtronic Kappa KD903, USA) for leads.1-3) Patients with myocardial perforation that’s re- treating her sick sinus syndrome. Active fixation lead lated to the pacemaker electrodes may present with va- (Medtronic 4068, USA) and passive fixation lead(Med- rious symptoms, from being asymptomatic to displaying tronic 4092, USA) were used for the atrial and ventri- cardiac tamponade. While most of these perforations cular leads, respectively. The routine laboratory findings, have been reported to occur within one month after im- including complete blood cell counts and blood chemi- plantation, delayed myocardial perforation is very rare.4) stry, were all normal. Her echocardiogram showed nor- We report here on one case of finding on follow-up a mal chamber sizes, a normal left ventricular ejection right ventricular perforation that was caused by the ven- fraction(LVEF) and no regional wall motion abnorma- tricular electrode one month after uneventful implan- lity. No significant coronary disease was noted on the tation of a permanent pacemaker. We surgically removed coronary angiogram. Three days after the procedure, she the electrode and repaired the perforated right ventri- was discharged without any complications. cular wall. Chest radiographs showed normal positioning of the electrodes until 32 days after the procedure(Fig. 2A-D). Case Yet we found that the sensitivity of the ventricle leads until 16 days after procedure was decreased from 11.2 A 68-year-old woman was admitted at our hospital to 4.8 mV, and the pacing threshold during the period because of her syncope. She had hypotension with a progressively increased from 0.25 to 4.0 V(Table 1). So, blood pressure of 80/40 mmHg and her electrocardio- we changed her pacemaker mode to AAI on post-pro- graph(ECG) showed junctional rhythm without a sinus cedure day 16, and the sensitivity and pacing threshold of the ventricle leads was not improved on the following Received：January 3, 2007 check-up. Therefore, we decided to reposition the ven- Accepted：May 30, 2007 tricular lead. On post-procedure day 36, she complained Correspondence：Byoung Kwon Lee, MD, Division of Cardiology, Depart- palpitation and chest discomfort. Chest radiographs ment of Internal Medicine, Sanggye Paik Hospital, Inje University Medical showed that the ventricular lead was straightened and College, 761-1 Sanggye 7-dong, Nowon-gu, Seoul 139-707, Korea Tel: 82-2-950-1212, Fax: 82-2-950-1429 displaced left and laterally downward(Fig. 3A, B). ECG E-mail: [email protected] showed normal ventricular function without any other

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454·Korean Circulation J 2007;37:453-457 related findings. The sensitivity of the ventricle lead was surgically removed the ventricular lead that had penetra- 4.0 mV and pacing was not captured(Table 1). The chest ted through the RV free wall and protruded 2 cm out computed tomography(CT) scan demonstrated clear evi- of the diaphragmatic reflection of the pericardium along dence of migration of the ventricular lead out of the the apex of the RV free wall side. Interestingly, the pe- heart onto the chest wall and diaphragm(Fig. 4A, B). We ricardial space was clear without any effusion or hema-

Fig. 1. The initial electrocardiograph (ECG) revealed junctional rhythm without a sinus p wave (A) and the longest pause was 3.45 sec (B).

A B

Chest PA Lt. Lateral view

C D

Chest PA Lt. Lateral view

Fig. 2. The chest posteroanterior and lateral films showed no significant interval change of the dual-chamber pacemaker electrodes, with the tip of each lead positioned in the right atrium and right ventricle, between two days after the procedure (A, B) and post-procedure day 32 (C, D). PA: posteroanterior, Lt: left.

Hye Kyung Park, et al：Right Ventricular Perforation by Electrode·455

Table 1. Testing of the pacemaker showed an increase in the right ventricular pacing threshold from 0.75 V at implant to 4.0 V. The sensitivity of the ventricle leads was also decreased Atrial lead Ventricular lead Post-procedural day S (mV) Imp (Ω) P (V) S (mV) Imp (Ω) P (V) 00 2.8 596 0.50 11.2 694 0.25 02 2.8 708 0.75 08.0 595 0.75 06 2.8 708 1.25 05.6 488 1.50 16 1.4 719 1.25 04.8 496 4.00 Mode chage to AAI, scheduled to reposition 23 1.4 799 0.75 04.6 412 5.00 32 1.4 734 0.75 04.6 * * *: not checkable, S: sensitivity, Imp: impedance, P: pacing threshold, AAI: atrium atrium inhibition

A B

Chest PA Lt. Lateral view Fig. 3. 36 days after pacemaker implantation, the chest radiographs show the antero-inferiorly displaced ventricular lead (arrow) beyond the cardiac shadow (A, B). PA: posteroanterior, Lt: left.

A B

Fig. 4. Axial scan of chest computed tomography demonstrated that the tip of the pacemaker lead (arrow) was located in the pericardial fat layer near the pericardium at 36 days after procedure (A, B). toma(Fig. 5). After disconnecting from the generator, plantation of these devices are ecchymosis, hematoma at gentle and steady traction resulted in lead extraction to the incision site and mild chest discomfort, but these an outward direction from the RV apex. On her pre- are usually temporary. But the procedure-related major operative EKG, the AV conduction was normal(Fig. 6), complication such as perforation of the major arteries so a new ventricular lead was not implanted at that time. or of the heart itself, pneumothorax and sepsis can be The AAI mode for the pacemaker was maintained. The fatal complications.1)2) Lead perforation is a rare com- patient was discharged after surgical removal of the lead. plication with an incidence of 0.3% to 1.2%,1)3)5) and She has been being well without any complication during moreover, late perforation is much more uncommon. the two year follow-up period. Early or delayed perforation of a ventricle might cause clinical symptoms. Dyspnea, palpitation or chest pain Discussion due to pericardial effusion, hemothorax and extracardiac muscle stimulation can develop.2) Also, the failure to pace Pacemakers and implantable cardioverter-defibrillators or sense appropriately, and also ventricular arrhythmia are used to treat a variety of heart rhythm problems. The might cause syncope or sudden cardiac death.6) However, usual complications for most patients undergoing im- a review of the medical literature4)7)8) showed that(dela-

456·Korean Circulation J 2007;37:453-457 yed) perforation may not have any symptoms. Chest dis- ning the pacemaker device with short regular follow-up comfort and palpitation for a few seconds at the one intervals under a high index of suspicion would be month follow-up visit were the only symptoms in our recommended for the early detection of pacemaker dys- case. function. Noticeable position change on the chest radio- In cases of suspected lead perforation, many physicians graphy may not be possible even after finding failure to can usually use work-up tools such as device analyzers, pace. computed tomography(CT) can be a very useful chest radiographs, ECG, echocardiography and fluro- adjunct to the other imaging modalities during the eva- scopy.5) The combined use of these devices will usually luation of possible lead perforation.9) Also, in the case allow a physician to arrive at a convincing diagnosis. of planning surgical treatment, CT scan can give exact There was no abnormality on the follow-up ECG and information on lead location and its relation to adja- chest radiographs, and there were no clinical symptoms cent organs. during the first two weeks in our case. Two weeks after The reasons for perforating a ventricle by the pace- this, we detected the change of the sensitivity and pa- maker lead might arise from many factors related to the cing threshold of the ventricular lead. The usual interval patients or the procedure. The factors related to patients of the follow-up schedule for patients with a new pace- are mainly due to a weakened ventricle from dilated maker is between two weeks and one month after the cardiomyopathy, ischemic cardiomyopathy or other myo- procedure. But we changed the follow-up visits to a wee- cardial inflammatory disease. A tough manipulation of kly schedule to check her pacemaker function and found the myocardial leads during pacemaker implantation the ventricular perforation five weeks after pacemaker belongs to the procedure-related factors when using a implantation. Therefore, frequent check-ups for exami- stiff stylet or an active fixation type lead. It assumed that lead perforation occurred in our patient because the movement of the ventricular lead near the right ventricular free wall would give an axial force to the apex when the right heart contracts. We suggest that a perforating ventricular lead should be removed even there is no other complication because there is the potential risk of cardiac tamponade. This case shows the potential for ventricular perforation by the pacemaker lead even after uneventful implantation of a passive fixation lead. It also reveals that late perforation by the pacing leads might occur without pacing electrode stimulation of the chest musculature or without any percardial effusion being present. A frequent follow-up schedule might be recommended when abnormal findings are noted on the immediate results of medial testing. We suggest for such cases as ours that Fig. 5. The thoracotomy view showing the exposed pericardial sac. The tip of the ventricular lead (arrow) protruded through the right ventricle a high index of suspicion is important even when the apex without causing pericardial effusion or hematoma. routine chest radiograph and surface ECG are normal.

Fig. 6. The AV conduction was normal (Fig. 6. ECG). AV: atrioventricular, ECG: electrocardiograph.

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