Late asymptomatic atrial lead perforation, a fortuitous finding during lead extraction using thoracoscopic surveillance: a case report and review of the literature

Abstract

A 61-year-old male patient was referred for lead extraction of an infected two-chamber pacemaker system first implanted 18 years ago. A new atrial lead was implanted 9 years later because of loss of capture of the original lead. Video-assisted thoracoscopic surgery (VATS) that we use in high-risk cases showed extensive fibrous adhesion between the right atrium wall and the right lung. Dissection of the adhesion revealed the presence of an atrial lead perforated into the lung. After cutting off the lead tip, the residual lead was removed endovascularly from the subclavian site. A literature review of 25 reported cases of late atrial lead perforation was added to the findings in our case report.

Bilateral Pneumothorax Complicating Pacemaker Implantation, due to Puncture of the Left Subclavian Vein and Electrode Perforation of the Right Atrium

“…If the defect caused by perforation of the cardiac wall is small and plugged immediately due to cardiomyocyte contraction, then a pericardial effusion is avoided and the pneumothorax can be stabilized. A larger cardiac perforation can lead to pericarditis, pericardial effusion, tamponade, hemodynamic instability [14] and even death; pleuritis, chest pain, dyspnea, hypotension, and syncope [12,[15][16][17][18], abnormal pacemaker function (primarily a high threshold or loss of capture) [9, 11-12, 14-17, 19] and extracardiac pacing (diaphragmatic, pectoralis or intercostal muscle stimulation [14][15]19] and inappropriate shock [17]. Pneumopericardium and pneumothorax and pleural effusion are very rare complications [3, 6-9, 15, 17].…”

“…Perforation, with the lead or the helix outside the cardiac silhouette, can be diagnosed by means of fluoroscopy, chest radiography, and echocardiography [14,19], but these methods are not reliable for evaluating less severe lead perforation [8-9, 17, 20]. The diagnostic gold standard is ECG-gated highresolution computed tomography (HRCT) [9], which has optimal demarcation of the interface between the myocardium, blood, and fat [12,15,[17][18][19][20], although star artifacts from the pacemaker wire sometimes make it difficult to precisely identify the lead tip [8-9, 17, 19-20], and there is a risk of over-diagnosing perforation [16]. Apart from aiding in making the diagnosis HRCT also helps in planning lead retrieval as it gives a good assessment of the orientation of vital structures around the displaced lead [9,16].…”

“…Leadless pacemakers seem to be associated with a slightly higher perforation risk. Implantable cardioverter-defibrillator (ICD) leads have a larger diameter and a higher rate of perforation, whereas cardiac resynchronization therapy defibrillator (CRTD)-implantation is associated with the highest risk of perforation [3,[6][7][8][11][12][14][15][16][17].…”

“…Appropriate management of asymptomatic lead perforation is a debated issue [16][17][18][19]. When there is a regression of the pneumothorax, no pericardial effusion, no clinical symptoms, and stable and acceptable lead parameters it may be considered to closely observe the patient with a conservative approach and to retain the electrode in situ [6][7], especially in the old and frail patient with an increased risk associated with lead extraction [15][16]; even in cases with helix perforation, awaiting fibrous tissue thickening and/or wrapping around the helix [17]. The long-term safety of this strategy is unknown [12,[18][19].…”

Tale of a Wandering Lead: Late Atrial Lead Perforation into Right Lung following Pacemaker Implantation

“…Late perforation is defined as perforation which occurs after discharge from hospital after successful placement. It is a rare but serious complication [ 3 ]. Presentation can vary from mild discomfort to sudden hypotension and death.…”