Introduction: Placements of pacemakers have become a routine procedures and are generally associated with low complication
rates. Late permanent pacemaker PPM lead perforation is an uncommon but clinically significant complication. Chest radiograph
is most commonly used imaging modality to diagnose the lead perforation by following the lead tip position. Usually it is easier to
diagnose if the lead tip is outside the cardiac shadow.
We, describe an accidentally discovered cardiac and diaphragmatic perforation with the PPM lead in one of our patients.
Case Description: A 70-year-old gentleman from a rural area underwent single chamber PPM implantation through left subclavian
vein approach for treatment of sinus node dysfunction. He was discharged in good condition and pre-discharge PPM interrogation
found loss of capture and intermittent sensing failure. Pre-discharge echocardiogram showed endocardial lead in situ.
After 6 months he came to the outpatient clinic for follow up, chest-X ray showed that the pacemaker lead is outside the cardiac
shadow perforating the right ventricle, pericardium and left diaphragmatic copula. CT scan with contrast of the chest confirmed the
diagnosis. As the patient was asymptomatic and his ECG showed normal sinus rhythm, so after discussing the case the consensus was
to take out surgically the whole PPM lead and the pulse generator as well.
In the operating room after left sub-mammary incision we saw the lead outside the heart so it was cut and the remaining proximal
part with the pulse generator was pulled out via the left subclavian incision. The right ventricle and the diaphragm were repaired and
the patient tolerated the procedure well and discharged home after few days in a good condition.
Conclusion: After PPM implantation, one should be aware of lead perforation. Interventricular septal fixation of the lead may decrease
the incidence of perforations.
The CT scan of chest should be done earlier to confirm the diagnosis in situations with high possibilities of lead displacement
along with close observation. |
