Right coronary artery perforation by an active-fixation atrial pacing lead resulting in life-threatening tamponade

Abstract

Cardiac tamponade resulting from perforation of a cardiac chamber is a relatively rare complication of pacemaker implantation. We report the first case of perforation of the right coronary artery related to the implantation of a screw-in atrial pacing lead, presenting as life-threatening cardiac tamponade. We report the case of a 72-year-old woman with complete atrioventricular block and dyspnea on exertion. A permanent pacemaker was implanted with bipolar Medtronic active-fixation leads positioned in the right atrial appendage and at the right ventricular basal septum without any difficulty. Approximately 3.5 h after the procedure, the patient complained of nausea, and the systolic blood pressure decreased to less than 60 mmHg. Echocardiography revealed a large pericardial effusion. Because the effects of pericardiocentesis lasted for less than an hour, the patient underwent a thoracotomy. After evacuation of a massive hemopericardium, bright red blood was seen gushing out from the right coronary artery, which was located on the opposite site of the right atrial appendage where a small portion of the screw tip was observed to be penetrating the atrial wall. The right coronary artery perforation was repaired using autologous pericardium-reinforced 7-0 prolene mattress sutures. Perforation of the right coronary artery is a potential complication and should be part of the differential diagnosis of cardiac tamponade after pacemaker implantation.

Keywords: Active-fixation atrial pacing lead; Cardiac tamponade; Pacemaker; Right coronary artery perforation.

Fig. 1

(A) Posteroanterior and left lateral chest radiographs recorded in the operation room show that the screw-in atrial lead was located in the right atrial appendage and the screw-in ventricular lead was located at the right ventricular basal septum. (B) A 12-lead ECG recorded 40 min after the pacemaker implantation demonstrates that the pacemaker was functioning normally with atrial sensing followed by ventricular pacing.

Fig. 2

(A) Intraoperative image of bleeding from the right coronary artery. After evacuation of 1400 mL of hemopericardium along with several thrombi, we determined that bright red blood was gushing out from the right coronary artery, which was located on the opposite side of the right atrial appendage to the atrial lead screw. (B) Intraoperative drawing corresponding to (A). Bleeding site and right coronary artery are drawn illustrated. RV, right ventricle; RAA, right atrial appendage.

Fig. 3

(A) Intraoperative image showing the atrial lead screw penetrating the right atrial appendage, which was located on the opposite side from the bleeding site. There was no bleeding from the screw tip penetration site. (B) The magnification of (A) is shown. A semi-circular portion of the screw penetrated the atrial wall. The diameter of the screw was 1.17 mm. RAA, right atrial appendage; RA right atrium.