Background: Implantation of pacemaker (PM) and implantable cardioverter defibrillator (ICD) leads is associated with a small, but serious risk of cardiac perforation. Appropriate management is still uncertain.
Objective: This study assessed the management approach and outcome of subacute or delayed cardiac perforation by PM or ICD leads.
Methods: The study population included all patients referred to a single institution for subacute or delayed lead perforation following a PM or ICD implantation (identified after hospital discharge) during the period 2008-2018. The approach and outcome of lead management were retrospectively assessed.
Results: Twenty eight cases of cardiac perforation were identified (seventeen female, mean age: 69.5 years old). The perforation was related to a PM (n = 17) or an ICD (n =11) lead. Eighteen perforating leads were originally placed at the right ventricular (RV) apex, eight at the RV outflow tract or septum, and 2 at the right atrial fee wall.
The main symptoms were major dyspnea with pericardial effusion (n = 7) or hemothorax (n = 2), chest pain (n = 6), diaphragm stimulation (n = 6), and abdominal pain (n = 2). Eleven patients were asymptomatic. All 28 patients had altered lead electrical parameters at device interrogation.
The diagnosis of lead perforation was confirmed by chest x-ray, echocardiography, or computed tomography. In all patients, the leads were removed or repositioned by the percutaneous approach. The perforating lead was manually retracted and repositioned to a different intracardiac location (in 12 patients), extracted by manual traction (n = 12), or extracted using laser-powered sheath (n = 4). None of the patients required surgical intervention. In the patients with pericardial effusion or hemothorax, pericardiocentesis and thoracentesis were performed before the lead revision procedure. None of the patients developed acute periprocedural complications.
Conclusion: In this largest series to date of subacute or delayed cardiac device lead perforation, percutaneous repositioning or replacement of the perforating lead was found a safe and effective management approach.