Perforation of right ventricle by pacemaker lead

Clinical History

A 45-year-old gentleman was referred for an emergency computed tomography (CT) scan immediately after pacemaker insertion. The patient was in shock and vascular injury during cardiac resynchronization therapy (CRT) was suspected.

Imaging Findings

The CT scan showed pacemaker lead extending through the right ventricular (RV) free wall and epicardial fat pad into the pericardial cavity (Fig. 1). There is evidence of hyperdense pericardial effusion in keeping with haemopericardium due to RV perforation. In addition, a persistent left superior vena cava (SVC) is seen along with right SVC (Fig. 2 and 4). The reconstructed image shows the course of RV lead causing cardiac perforation (Fig. 3)

Discussion

Perforation of right ventricle by pacemaker lead:

Cardiac chambers perforation by an endocardial lead is an uncommon, but potentially dangerous, complication of implantation of a pacemaker or a cardioverter defibrillator (ICD) [1].

Chest radiograph is an easy and commonly used diagnostic method for detecting pacemaker perforation. On chest radiograph, a diagnosis of pacemaker perforation can be made if the lead is located beyond the confines of the cardiac silhouette. A lateral view of the chest should always be performed as it can localize the position of the pacemaker lead more accurately. Chest X-ray can also detect extracardiac complications such as pleural or pericardial effusion and pneumothorax. Echocardiography (ECHO), a simple and noninvasive test that can be performed easily at the bedside, can also help to assess electrode location and detect presence of the pacemaker lead tip in the pericardium and presence of pericardial effusion. However, both of these diagnostic tests have their limitations and the location of the pacemaker lead tip may not be correctly located. CT scan of the chest is currently regarded as the gold standard in the diagnosis of pacemaker lead perforations. Performing CT scans is standard care in most departments dealing with cardiac implantable electronic devices implants. Chest CT accurately reveals pacemaker lead displacement which can sometimes be missed by chest radiograph or ECHO. In addition, it can confirm the presence of an associated pericardial effusion or pleural effusion. However, caution should be exercised as the position of pacemaker wires may be misinterpreted on CT due to artefacts [2].

To conclude, CT is an extremely useful imaging modality to confirm diagnosis and aid planning of extraction. CT allows ready identification of the course of the lead, relationship to adjacent anatomy and adverse sequelae such as pericardial effusion [3].

SVC duplication:

A persistent left SVC is an incidental finding in less than 0.5% of the general population. In most cases, the left SVC is a component of a duplicated SVC and left brachiocephalic vein is absent. As an isolated anomaly in the absence of congenital heart disease, a left SVC or left component of a duplicated SVC almost always drains into the coronary sinus. A left-sided SVC is most often not clinically significant, but can cause difficulty in manipulation and stabilisation of ventricular leads as it takes acute angle after coming out of coronary sinus to cross the tricuspid valve, and to reach the RV apex [4].

Differential Diagnosis List

Final Diagnosis

Perforation of right ventricle by pacemaker lead.Incidental SVC duplication.

URL:	https://www.eurorad.org/case/13731
DOI:	10.1594/EURORAD/CASE.13731
ISSN:	1563-4086