A Transvenous Pacing Lead's Journey Leading to Perforation and Hematothorax

Abstract

Recognition of lead-related complications after cardiac implantable electronic device implantation is challenging. An 86-year-old woman with a cardiac resynchronization therapy pacemaker (CRT-P) presented with recurrent nonspecific symptoms, including pulse-synchronous abdominal pain and dyspnea, over 3 emergency department visits. Right ventricular lead perforation went undiagnosed until significant hemothorax developed. A review of electrocardiographic (ECG) and chest X-ray images from earlier visits revealed that lead perforation could have been diagnosed earlier. This case underscores the diagnostic challenges of CIED complications, especially in patients with nonspecific symptoms. Key findings, such as ECG morphology changes and atypical lead position on X-ray, were missed because of limited knowledge of pacemaker-ECG interpretation and inattentional blindness. Lead perforation may occur several weeks after cardiac implantable electronic device implantation. In CRT patients, a predominantly positive stimulated QRS complex in lead V₁ indicates possible loss of right ventricular capture as a possible sign of perforation.

Keywords: cardiac resynchronization therapy; lead perforation; pacemaker.

Graphical abstract

Figure 1

Chest Radiography Posteroanterior (left) and lateral (right) views taken the day after cardiac resynchronization therapy-pacemaker implantation, where correct positioning of all 3 leads can be appreciated. Notably, the right ventricular lead is implanted in an apical position.

Figure 2

Electrocardiograms on Day 18 and 21 After TAVI (A) ECG performed during the patient’s first presentation to the emergency department on day 18, which confirmed correct biventricular pacing. (B) ECG performed during the second presentation on day 21, showing a paced QRS complex that is broad and positive in lead V₁, exhibiting a right bundle branch block pattern. This finding is indicative of left ventricular capture only and raises suspicion for loss of right ventricular capture.

Figure 3

Chest Radiography Before and After Chest Tube Placement on Day 21 (A) Chest X-ray performed on day 21, revealing a significant left-sided pleural effusion. Notably, even on this X-ray, the position of the right ventricular lead appears atypical and markedly different from its position on the X-ray following cardiac resynchronization therapy-pacemaker implantation (Figure 1). (B) Chest X-ray taken immediately after drainage of 1.3 L of blood. The chest tube is correctly positioned, and the pleural effusion has been largely resolved. additionally, it is now evident that the right ventricular lead is no longer within the heart boundaries and has perforated into the left lung, resulting in the hemothorax.

Figure 4

Course of Right Ventricular R-Wave Amplitude and Pacing Impedance Since CRT-P Implantation Lead trends indicating R-wave amplitude over time (upper part) and right-ventricular bipolar pacing impedance (lower part). It can be appreciated that both R-wave amplitude and impedance were initially relatively stable until a sudden rise in impedance (from approximately around 600 to 850 Ohm), followed by a sharp drop of >350 Ohm; simultaneously, the R-wave amplitude dropped abruptly to approximately 1 mV, indicating the moment of lead perforation.

Figure 5

Intraoperative Image During Lead Extraction Intraoperative image showing the extracardiac portion of the perforated right ventricular lead.

Figure 6

Chest Radiography and ECG After Lead Extraction and Re-Implantation (Left) Postoperative chest X-ray showing correct position of the right ventricular pacemaker lead at the right ventricular outflow tract. (Right) ECG at 6-month follow-up visit showing correct biventricular pacing.

Visual Summary

Timeline of the Events CRT-P = cardiac resynchronization therapy-pacemaker; CT = computed tomography; ECG = electrocardiogram; ER = emergency room; RV = right ventricular; TAVI = transcatheter aortic valve implantation.