A Case of Delayed Right Ventricular Pacemaker Lead-Associated Perforation Causing Cardiac Tamponade

Right ventricular perforation by pacemaker leads is often reported. However, reports of delayed lead perforation, defined as the perforation that occurs >1 month after implantation, are rare. Despite the fact that delayed pacemaker lead perforation can be an emergency, no clear treatment strategy has been defined. Herein, we report our experience with a case of delayed lead-associated perforation causing cardiac tamponade. A 60-year-old man presented to the emergency room with chest and back pain and dyspnea. He had undergone pacemaker implantation for advanced atrioventricular block eight years ago. He was found to have cardiac tamponade due to right ventricular lead-associated perforation. Emergency surgery was performed to drain the fluid and control the bleeding via a median sternotomy. The lead screw had perforated a vein on the cardiac surface. The perforating lead was retained because the threshold and impedance of the lead were unchanged. Only the perforation was repaired. After seven days, the ventricular lead threshold increased. This was managed by adjusting the pacemaker settings. The patient tolerated the procedure well and was discharged home. The treatment of right ventricular lead-associated perforation generally entails removal and reinsertion of the lead. However, in our patient, a definitive diagnosis could not be made before the operation because the right ventricle was not completely perforated by the lead tip. Furthermore, the patient had concomitant cardiac tamponade with signs of shock. Therefore, open surgery was performed. After the perforation site is repaired, the area around the myocardium may deteriorate for several reasons (e.g., edema, fibrosis, and partial myocardial tissue necrosis). Therefore, if the pacemaker lead cannot be removed (or reinserted), as in our patient, measures such as insertion or implantation of a temporary pacemaker lead need to be taken in anticipation of deterioration of the myocardium around the retained lead.