Delayed Right Ventricular Perforation by a Transvenous Active Fixation Implantable Cardioverter-Defibrillator Lead
Echocardiographic Diagnosis and Surgical Management
A 27-year-old woman with a past medical history of congenital long-QT syndrome was admitted to our hospital because of a sudden loss of consciousness. Four weeks before she had been implanted an implantable cardioverter-defibrillator (ICD) in another hospital because she had presented with a pulseless syncopal episode that required cardiopulmonary resuscitation, with documentation of runs of polymorphic ventricular tachycardia. The ICD was a single-chamber Biotronik Lumax VR-T with an active fixation-lead Biotronik Linox-S tripolar placed in the right ventricular apex. At admission to our hospital, her blood pressure was 85/40 mm Hg, and blood analysis showed hemoglobin of 8 g/dL and hematocrit of 27%. The thorax x-ray showed an ICD lead apparently located in the right ventricular apex. The echocardiographic study demonstrated severe pericardial effusion and showed clearly how the tip of the ICD lead had perforated the right ventricular apex, going in and out of the ventricle with each cardiac movement (Figure, A, online-only Data Supplement Movie I). It was decided to remove the system in the operating room. A median sternotomy was made and the heart was exposed (Figure, B, online-only Data Supplement Movie II), confirming the echocardiographic diagnosis of delayed right ventricular apex perforation by the ICD lead. The lead, which crossed the myocardium very close to the left anterior descending artery, was removed under visual control, and the right ventricular apex was sutured without the need of extracorporeal circulation. Finally, the ICD lead was repositioned at the right ventricular middle septum without complications.
Late ventricular perforation is a serious complication of ICD implantation that is seldom reported in the literature1 possibly because early perforation is more frequent. Because of the low incidence of late ventricular perforation, predisposing factors are not well understood. In the cases reported, late cardiac perforation has been confirmed when necessary by right ventriculography2 or, more often, by chest computed tomography.3–6 As far as we know, echocardiography has not been reported as a method to confirm the cause of cardiac tamponade in these cases. In our case, echocardiographic images clearly showed the tip of the lead going in and out through the right ventricular wall into the pericardial space, confirming the diagnosis of delayed right ventricular perforation by the ICD lead.
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/119/15/2112/DC1.