Perforation of right ventricle with cardiac tamponade following pacemaker implantation.

Sir,

Right ventricular rupture resulting from pacemaker implantation is a critical cardiac complication associated with cardiac tamponade and death. It is usually at the time of lead insertion. This condition requires urgent recognition since the prompt drainage of the pericardial fluid may be lifesaving. We report a case of cardiac tamponade that resulted from pacemaker implantation.

A transitory pacemaker was implanted to 72 years old female, before carrying out a valvuloplasty by a severe Aortic stenosis (peak gradient 100 mmHg and mean gradient 70 mmHg). After carrying out the valvuloplastia with a successful result (gradient reduction of 50%) the patient was admitted to the intensive care unit (ICU) for monitoring, 30 min later she suffered arterial hypotension, requiring inotropic support, and the central venous pressure increased from 12 to 20 mmHg. With the suspicion of a cardiac tamponade, a transthoracic echocardiography was carried out, detecting a pericardial effusion of 20 mm with commitment of diastolic filling [Figure 1]. Pericardial drainage was carried out and the patient was taken to the operating room practicing an urgent thoracotomy, during which she suffered a cardiac arrest, so cardiopulmonary reanimation maneuvers were carried out. During surgery, through left thoracotomy, two myocardial perforation spots were observed in the apical wall of the right ventricle, which were sutured [Figure 2]. Patient died despite emergency surgery by refractory shock.

Figure 1

Transthoracic echocardiography: pericardial effusion of 20 mm with commitment of diastolic fi lling

Figure 2

Two myocardial perforation spots observed in the apical wall of the right ventricle

Acute complications resulting from permanent pacemaker implantation are well known and include perforation of the right atrium or right ventricle. Recently, several reports have described the occurrence of perforation and pericarditis as late complications following pacemaker implantation. These complications may occur days to weeks following uncomplicated pacemaker implantation and may lead to death if they are not recognized early.[12 A review of the literature revealed that cardiac tamponade is a rare complication of pacemaker implantation, we should be aware of possible complications and be prepared to treat them.[3]

Real-time echocardiography and color Doppler provide excellent visualization of right ventricular rupture. Occasionally, the site of rupture may be contained by the parietal pericardium and thrombus, thus forming a pseudoaneurysm.[4]

The fragility of the myocardium in the elderly is considered to be a major reason for this complication which may occur despite the use of flexible electrodes and correct technique.[5 A higher clinical suspicion should be maintained in the elderly in whom perforation occurs more frequently.