Atrial lead perforation early after device implantation: A case series.

Introduction

An overall complication rate between 5.3% and 14.3% is observed for cardiac device implantations. The complication risk increases with rising number of electrodes used and is higher in the case of redo procedures. Complications can be divided by their timing into interprocedural, periprocedural (within 7 days), or late (after 7 days) and occur after access site problems using a subclavian or axillary puncture, or are related to lead placement itself owing to dislocation or perforation. Finally, infection and lead malfunction can occur.

Lead perforations in the context of permanent pacemaker or implantable cardioverter-defibrillator implantations are rare (<1%), with a broad spectrum of typical and atypical symptoms. The affected lead is more often the right ventricular lead (owing to apical or free wall perforation) than the atrial electrode and the therapy of choice is lead extraction or repositioning of the affected electrode to avoid further migration.1, 2, 3, 4, 5

Atypical secondary complications include left-sided hemothorax owing to vascular access problems, or a perforation of the right ventricular lead with additional damage to lung tissue or smaller vessels within the lung, with possible lead migration into the pleural space or the lung. Right atrial (RA) perforation with damage of the right lung can result in a rare right-sided hemothorax.

The range of clinical presentation is wide: from asymptomatic (presence on heart computed tomography [CT] in 6%–15% of asymptomatic patients), to symptomatic with thoracic pain or fatigue, coughing, and dyspnea (with or without minimal pericardial effusion), to distress (with pericardial tamponade).

Since the complication spectrum is very broad, early detection and appropriate response are important to optimize management. The present case series discusses solely RA lead perforations.

It is important to be aware of the different presentations of (rare) complications after pacemaker implantation and to make appropriate recommendations for early detection and therapy.

This article points out the diagnostic importance of early computed tomography.

The diagnosis of a lead perforation should be made in consideration of all diagnostic findings, since an inconspicuous device control cannot exclude a perforation.

Case report

Case 1: Atrial lead perforation resulting in urgent surgical repair

An 82-year-old male patient presented with symptomatic sick sinus syndrome and multiple syncope, which led to an uncomplicated implantation (35 minutes skin-to-skin time) of a dual-chamber pacemaker. The patient’s medication contained aspirin, antidiabetic therapy, and antihypertensive medication without the need for oral anticoagulants (Table 1).

Table 1

Baseline and procedural data

Case #	Antiplatelet or NOAC	Sex	BMI	Duration (min)	X-ray time (min)	Access RA lead	Access RV lead		RA lead position	RV lead position	X-ray dose (Cgy/cm2)
1	Aspirin 100 mg	Male	30.8	35	2.3	Subclavian vein		Subclavian vein	RAA	RV apex	95
2	Aspirin 100 mg	Male	27.0	33	3.1	Cephalic vein		Cephalic vein	RA lateral	RV apex	106
3	Aspirin 100 mg	Female	24.7	35	2.1	Subclavian vein		Subclavian vein	RA lateral	RV apex	43
4	Apixaban 5 mg	Male	24.3	115	18	Subclavian vein		Subclavian vein	RA lateral	RVOT	909

BMI = body mass index; NOAC = novel oral anticoagulant; RA = right atrium; RAA = right atrial appendage; RV = right ventricle; RVOT = right ventricular outflow tract

The atrial lead was fixed actively in the anterolateral right atrial appendage (RAA) and the ventricular lead in the apical right ventricle (RV) (Figure 1A). The patient was hemodynamically stable and free of any complaints during and immediately after the procedure.

Figure 1

Atrial lead perforation treated with urgent cardiac surgery. A: Chest radiograph immediately post implant: atrial lead is fixed into the right atrial appendage and the ventricular lead has been fixed in the right ventricle (arrows). B: Supine position, sternotomy. Surgical pincers holding the perforated right atrial electrode (arrow). The pericardial drain is still visible (asterisk). LV = left ventricle; RAA = right atrial appendage; RV = right ventricle.

Early postoperative (approximately 5 minutes after skin closure) echocardiography revealed a hemodynamically irrelevant pericardial effusion (5 mm end-diastolic). Because of that, a device check was performed subsequently after echocardiography and demonstrated varying atrial sensing values (Table 2), good pacing thresholds of both leads, and normal lead impedances (unipolar and bipolar). The patient continued to be closely monitored and developed a pericardial tamponade, leading to an emergency pericardiocentesis resulting in the withdrawal of 600 mL of fresh blood.

Table 2

Periprocedural measurements

Lead used	Right atrium	Right ventricle	Right atrium	Right ventricle	Right atrium	Right ventricle	Right atrium	Right ventricle
	Case 1		Case 2		Case 3		Case 4
	Medtronic 5076 CapSureFix Novus MRI 52 cm (Medtronic Inc, Minneapolis, MN)	Medtronic 5076 CapSureFix Novus MRI 58 cm	BiotronikSolia S 53	BiotronikSolia S 60	Medronic 5076 CapSureFix Novus MRI 52 cm	Medtronic 5076 CapSureFix Novus MRI 58 cm	Medtronic 5076 CapSureFix Novus MRI 52 cm	Boston Scientific Ingevity MRI 59 cm (North Charleston,,SC)
Threshold intraoperatively	0.6 V / 0.4 ms	0.4 V / 0.4 ms	1.0 V / 0.4 ms	0.8 V / 0.4 ms	0.8 V / 0.4 ms	0.7 V / 0.4 ms	1.1 V / 0.4 ms	0.6 V / 0.4 ms
Impedance intraoperatively	620 ohms	780 ohms	468 ohms	663 ohms	760 ohms	680 ohms	448 ohms	757 ohms
Sensing intraoperatively	3.2 mV	12.5 mV	4.2 mV	7.4 mV	3.0 mV	13.0 mV	2.2 mV	6.8 mV
Threshold postoperatively	Bi 0.8 V / 0.4 msUni 1.0 V / 0.4 ms	Bi 0.5 V / 0.4 msUni 0.75 V / 0.4 ms	1.0 V / 0.4 ms	0.8 V / 0.4 ms	0.9 V / 0.4 ms	0.6 V / 0.4 ms	0.4 V / 0.4 ms	0.5 V / 0.4 ms
Impedance postoperatively	Bi 600 ohmsUni 450 ohms	Bi 740 ohmsUni 700 ohms	510 ohms	650 ohms	680 ohms	650 ohms	405 ohms	795 ohms
Sensing acute postoperatively	Varying:Bi 2.0–3.1 mVUni 1.5–2.3 mV	Bi 14.0 mVUni 11.0 mV	2.0 mV	8.1 mV	2.7 mV	13.8 mV	2.6 mV	6.4 mV

Bi = bipolar; RAA = right atrial appendage; Uni = unipolar.

Since the bleeding did not stop by draining the pericardial effusion, the indication for thoracotomy was given. Intraoperatively it was shown that the atrial lead perforated up to 5 cm distally through the RAA (Figure 1B). After successful explantation of the RA lead the site of perforation was closed with a small patch and an epicardial atrial electrode was implanted. The patient was discharged after 7 days. At present, the patient is still alive and continues to show satisfactory pacemaker measurement values.

This case described an (acute) atrial lead perforation during dual-chamber pacemaker implantation. Changing sensing values could have suggested unstable positioning. Routine postoperative cardiac ultrasound can trigger closer or longer postoperative monitoring in patients with minimal pericardial effusion. Furthermore, the rapid management of this complication is extremely important. The acute development of a hemodynamically relevant pericardial effusion is probably the most dramatic consequence of a lead perforation.

Case 2: Atrial lead perforation with right-sided hemothorax

An 84-year-old patient with low bleeding risk (solely low-dose aspirin and normal platelet count), was planned for dual-chamber pacemaker implantation with recurrent syncope caused by prolonged sinus arrests. The implantation was uneventful (33 minutes skin-to-skin time), with insertion of both leads via the left cephalic vein. The atrial lead was fixed actively in the lateral RA and the ventricular lead in the apical RV (Figure 2A, Table 1). The patient was asymptomatic during the procedure and intraoperative device measurements proved to be satisfactory (Table 2).

Figure 2

Manifestations of atrial lead perforations, right-sided hemothorax. A: Chest radiograph immediately post implant: right atrial lead is fixed at the lateral right atrium (RA) and the ventricular lead has been fixed in the right ventricle (arrows). B: The right atrial electrode perforated the RA lateral wall with the tip 13 mm outside of the atrial silhouette. C: Chest radiograph post implant: right atrial lead is fixed at the lateral RA and the asterisk on the left side shows a lung infiltration. D: Chest radiograph post revision: right atrial lead has been relocated to the right atrial appendage. The asterisk on the left side of the picture shows the unchanged lung infiltration.

Postprocedurally, the patient suddenly complained of breath-dependent thoracic stabbing with a pain intensity of 7 on the Visual Analogue Scale (VAS). The pacemaker measurements were normal as well as the echocardiographic control immediately after implantation. The patient responded well to analgesic therapy. Regressive symptoms and continued satisfactory device measurement values (Table 2) resulted in patient discharge the following day.

Four days later, he presented to the emergency department with recurrent breath-dependent thoracic stabbing (VAS 8). Pericardial effusion was still absent on cardiac ultrasound and both unipolar and bipolar pacemaker measurements remained fine.

Owing to the timeline and symptom characteristics, a lead perforation was suspected and a CT of the thorax was performed. Heart CT confirmed a perforated atrial electrode (Figure 2B) with lead tip protrusion of approximately 13.7 mm from the pericardium into the right lung. The lead did not penetrate the pleura because no pneumothorax was visible. No pericardial fluid was observed. Furthermore, a right-sided hemothorax, most likely caused by vascular injury in the context of the perforation, was found. Therefore, lead revision with RA lead extraction and subsequent drainage of 700 mL of bloody effusion was performed. The patient remained hemodynamically stable periprocedurally. The thoracic drainage was removed on the second day and the patient was discharged at day 7. During follow-up, the patient remained asymptomatic and no recurrence of hemothorax occurred.

This case is illustrative because the RA lead perforated through the pericardium into the right lung, in the absence of a tamponade, resulting in an isolated right-sided hemothorax. There was neither an injury of the pleura (absence of pneumothorax) nor an injury of larger vessels close to the heart—which tend to develop left-sided hemothoraces. A clinical key fact was the atypical breath-dependent stabbing, often pathognomonic for lead perforation. This case also demonstrates the diagnostic importance of CT, as it quickly identified not only the cause of the symptoms, but also the lead involved (RA lead) and the accumulation of fluid (hemothorax) in the right lung. A CT scan should therefore be performed at a very early stage if a lead perforation is suspected or typical symptoms are described.

Case 3: Severe chest pain requiring lead repositioning

A 63-year-old female patient with a symptomatic binodal disease and normal systolic left ventricle function was assigned for elective implantation of a dual-chamber pacemaker (35 minutes skin-to-skin time, Table 1). Postprocedurally, an uneventful echocardiographic and device control was observed. Shortly before transfer back to the ward, the patient complained of severe breath-dependent left-sided pain (9 on the VAS). Radiography of the thorax immediately after implantation revealed (retrospectively) an infiltration area in the right lower lung (Figure 2C and 2D). Owing to typical respiratory complaints, lead revision of both electrodes was performed. After RA lead repositioning (RA: lateral to RAA and RV: apical to inferoseptal), the symptoms immediately disappeared and the patient remained hemodynamically stable during the entire procedure and the whole hospitalization. Device control was also inconspicuous and the patient was discharged the following day without any complains.

The third case highlights the importance to always consider perforation if patients have postprocedural chest pain, even if all measured values are inconspicuous. A contralateral clinical or radiological pulmonary anomaly should raise suspicion for lead perforation; even though this type of complication is very rare, cases of atrial lead perforation with following right-sided pneumothorax are described in the literature., In this particular case, a CT scan would also have been very helpful, as it would have given more information regarding the lead and the damage caused (especially pulmonary damage: pneumothorax vs hemothorax).

Case 4: Atrial lead microperforation with Dressler syndrome

An 82-year-old patient was implanted with a dual-chamber pacemaker for symptomatic sick sinus syndrome. Owing to a history of paroxysmal atrial fibrillation the patient was on oral anticoagulants (apixaban 5 mg twice/day), which had been stopped 24 hours before implantation. The implantation procedure itself was difficult (115 minutes skin-to-skin time, Table 1) owing to multiple repositioning of the RV lead because of right ventricular low voltage at the entire septum. Postprocedural measurements and echocardiography were satisfactory, but the patient complained of breath-dependent thoracic stabbing immediately after implantation. On the first postoperative day, symptoms were decreasing, but the echocardiographic control showed a minimal pericardial effusion without hemodynamic relevance (Figure 3B). After 3 weeks of intermittent symptoms, a CT scan of the thorax was performed, which revealed a pericardial effusion and a perforated atrial electrode tip (Figure 3C). Since the pericardial effusion was not hemodynamically relevant, the oral anticoagulation was reduced to 2 weeks of low-dose 2.5 mg apixaban (owing to low risk of thromboembolic events), which resulted in regression of the pericardial effusion. After resumption of full-dose novel oral anticoagulants, relapse of the effusion was observed, so that finally extraction of the atrial lead was performed, as well as a drainage of the stable pericardial effusion (Figure 3D). A total of 900 mL of brownish tinted transudate was drained and revealed a Dressler syndrome. The patient was free of complaints and, after 3 months of prednisolone and colchicine therapy, without recurrence of effusion.

Figure 3

Atrial lead perforation and Dressler syndrome. A: Chest radiograph immediately post implant: the atrial lead was fixed at the lateral right atrium (RA) and the ventricular lead was positioned in the right ventricular outflow tract (RVOT) (arrows). B: Postoperative echocardiography shows a minimal pericardial effusion (arrow) in front of the right ventricle (RV). C: Computed tomography scan revealed a perforated right atrial lead with pericardial effusion. D: Chest radiograph after drainage of the pericardial effusion: the arrow illustrates the RV lead fixed in the RVOT and the asterisk indicates the pigtail catheter. Ao Asc = ascending aorta; SVC = superior vena cava.

The last case demonstrates another possible course of a lead perforation. The supposedly uncomplicated atrial lead caused a microperforation with chronic inflammation and Dressler syndrome.

Conclusion

All the cases presented are intended to sharpen our clinical understanding that in the case of typical complaints of the patient, early revision of the leads (ventricular and atrial) should be generously considered, as this intervention can significantly facilitate the further clinical course. RA lead placement and fixation is operator-dependent, but 3 positions are recommended: RAA, anterior RA, and lateral RA, wherein the lateral atrial wall tends to be a muscle-weak (thin) area of the RA, so that a majority of implanters prefer the RAA (also because of the easy access with pre-bent stylet). However, this case series demonstrates that even if the RA lead is fixed in the supposedly less vulnerable RAA, pronounced complications can occur, so that appropriate caution should be exercised here as well. Furthermore, CT is a very fast, meaningful, and nowadays almost always and everywhere available diagnostic tool. Based on the cases presented, it is clear to see how accurate, fast, and sensitive this diagnosis can be performed to identify both the underlying problem and the affected pacemaker lead. Finally, every operator should be aware of almost all possible complications—even very rare ones like a right hemothorax after left-sided pacemaker implantation—based on the motto “expect the unexpected.”