Rib Perforation From a Right Ventricular Pacemaker Lead
2007; Lippincott Williams & Wilkins; Volume: 115; Issue: 14 Linguagem: Inglês
10.1161/circulationaha.106.669630
ISSN1524-4539
AutoresSunil Singhal, Joshua M. Cooper, Albert T. Cheung, Michael A. Acker,
Tópico(s)Cardiac Arrhythmias and Treatments
ResumoHomeCirculationVol. 115, No. 14Rib Perforation From a Right Ventricular Pacemaker Lead Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBRib Perforation From a Right Ventricular Pacemaker Lead Sunil Singhal, MD, Joshua M. Cooper, MD, Albert T. Cheung, MD and Michael A. Acker, MD Sunil SinghalSunil Singhal From the Division of Cardiothoracic Surgery (S.S., M.A.A.), Division of Cardiology, Section of Electrophysiology (J.M.C.), and the Department of Anesthesiology (A.T.C.), University of Pennsylvania School of Medicine, Philadelphia, Pa. , Joshua M. CooperJoshua M. Cooper From the Division of Cardiothoracic Surgery (S.S., M.A.A.), Division of Cardiology, Section of Electrophysiology (J.M.C.), and the Department of Anesthesiology (A.T.C.), University of Pennsylvania School of Medicine, Philadelphia, Pa. , Albert T. CheungAlbert T. Cheung From the Division of Cardiothoracic Surgery (S.S., M.A.A.), Division of Cardiology, Section of Electrophysiology (J.M.C.), and the Department of Anesthesiology (A.T.C.), University of Pennsylvania School of Medicine, Philadelphia, Pa. and Michael A. AckerMichael A. Acker From the Division of Cardiothoracic Surgery (S.S., M.A.A.), Division of Cardiology, Section of Electrophysiology (J.M.C.), and the Department of Anesthesiology (A.T.C.), University of Pennsylvania School of Medicine, Philadelphia, Pa. Originally published10 Apr 2007https://doi.org/10.1161/CIRCULATIONAHA.106.669630Circulation. 2007;115:e391–e392A 50-year-old man was admitted to a community hospital for high fever. Seven years earlier, he had been in a motor vehicle accident and a cervical spine injury had resulted in quadriplegia and ventilator dependence. During that hospitalization, he was noted to have long sinus pauses that were thought to be vagally mediated, and a single-chamber pacemaker was implanted to hasten his recovery, with an active fixation pacing lead placed at the right ventricular apex (Figure 1A through 1C). His bradycardia spells subsequently disappeared, and minimal pacing was needed. Download figureDownload PowerPointFigure 1. Serial chest radiographs showing the pacemaker lead position at the time of implantation (A), at initial hospital discharge (B), 7 months after implantation (C), and at the current admission (D). The position of the lead tip is designated by an arrow, and the lead tip is clearly located outside the rib cage (D).Because of spiking fevers, leukocytosis, and methicillin-resistent Staphylococcus aureus growing from blood cultures; a chest x-ray (Figure 1D) and a chest computed tomography scan (Figure 2) were performed. Neither revealed any obvious source of infection, but his ventricular pacing lead had perforated through the right ventricular apex, with the lead tip now sitting in soft tissue just outside the rib cage near the seventh rib. Download figureDownload PowerPointFigure 2. A reconstructed coronal slice from the chest computed tomography scan reveals the right ventricular lead penetrating the right ventricle, pericardium, and chest wall. The pacemaker is seen in the right prepectoral region (arrow), and typical motion and scatter artifact are seen along the course of the pacemaker lead (arrowheads). On some coronal slices (inset), the lead tip penetrates directly through the seventh rib (asterisk).Although it was not clear whether the pacemaker lead was infected in either its intravascular or extracardiac course, it was decided that the lead should be removed to avoid future mechanical complications at the least. The patient was referred for surgical pacemaker-system extraction. In the operating room, chest wall exploration revealed ventricular lead penetration through the seventh rib (Figure 3A). Local granulation tissue and a short segment of the perforated rib were resected (Figure 3B) and sent for culture. The lead was disconnected from the right pectoral pacemaker generator, and manual traction was used to free the lead from intravascular binding sites. The apical defect in the right ventricle was closed with a purse-string suture. There was no evidence of bleeding or cardiac tamponade. The excised granulation tissue and rib fragment did not reveal bacteria on Gram's stain, and tissue cultures showed no growth. The patient recovered well, with resolution of bacteremia after removal of an indwelling intravenous catheter and a course of antibiotics. Download figureDownload PowerPointFigure 3. A, Surgical dissection to expose the seventh rib through the left chest wall revealed that the pacemaker lead had fully eroded through the center of the rib. B, Resected segment of the seventh rib with the explanted pacemaker lead positioned through the perforation.This case illustrates the unusual complication of a delayed pacemaker lead perforation with erosion through bone. Myocardial perforation with pericardial effusion and cardiac tamponade is a short-term complication of pacemaker implantation in 1% of patients.1 Late perforation of pacemaker leads is far less common, with a variety of time frames, symptoms, and clinical findings reported.2–7 The clinical presentation may include extracardiac muscle stimulation, pericardial tamponade, chest pain, or even incidental discovery during an imaging procedure, as in the current case.If the perforated lead is to be percutaneously extracted, there must be extreme vigilance for the possible development of pericardial effusion and cardiac tamponade after the lead is withdrawn. Such procedures are best performed in an operating room setting under general anesthesia with transesophageal echocardiography, where close monitoring and rapid surgical rescue is possible. If the lead tip has migrated beyond the pericardium, referral for surgical extraction is the safest option, with the ability to directly visualize and repair the site of perforation and to deal with injury to adjacent structures.Because late lead perforations are quite rare, the predisposing factors are not well understood. Low-profile leads might pose an increased risk for perforation because there would be a higher force per unit area at the lead tip compared with a larger-caliber lead. Active fixation leads are more commonly reported to cause late perforation. Forces at the lead tip are complex, vary during the cardiac cycle, and may change over time. The interplay between longitudinal forces along the lead tip and the ability of the local myocardium to withstand those forces will result in either lead stability or lead perforation, with the former predominating in the vast majority of cases. Lead positioning plays a role, with placement on the interventricular septum likely posing less risk than implantation in the right ventricular apex or free wall.DisclosuresNone.FootnotesCorrespondence to Joshua M. Cooper, MD, 3400 Spruce Street, 9 Founders Pavilion, Philadelphia, PA 19104. E-mail [email protected]References1 Mahapatra S, Bybee KA, Bunch TJ, Espinosa RE, Sinak LJ, McGoon MD, Hayes DL. Incidence and predictors of cardiac perforation after permanent pacemaker placement. Heart Rhythm. 2005; 2: 907–911.CrossrefMedlineGoogle Scholar2 Polin GM, Zado E, Nayak H, Cooper JM, Russo AM, Dixit S, Lin D, Marchlinski FE, Verdino RJ. Proper management of pericardial tamponade as a late complication of implantable cardiac device placement. Am J Cardiol. 2006; 98: 223–225.CrossrefMedlineGoogle Scholar3 Selcuk H, Selcuk MT, Maden O, Ozeke O, Celenk MK, Turkvatan A, Korkmaz S. Uncomplicated heart and lung perforation by a displaced ventricular pacemaker lead: a case report. Pacing Clin Electrophysiol. 2006; 29: 429–430.CrossrefMedlineGoogle Scholar4 Greenberg S, Lawton J, Chen J. Images in cardiovascular medicine. Right ventricular lead perforation presenting as left chest wall muscle stimulation. Circulation. 2005; 111: e451–e452.LinkGoogle Scholar5 Sanoussi A, El Nakadi B, Larkinois I, De Bruyne Y, Joris M. Late right ventricular perforation after permanent pacemaker implantation: how far can the lead go? Pacing Clin Electrophysiol. 2005; 28: 723–725.CrossrefMedlineGoogle Scholar6 Akyol A, Aydin A, Erdinler I, Oguz E. Late perforation of the heart, pericardium, and diaphragm by an active-fixation ventricular lead. Pacing Clin Electrophysiol. 2005; 28: 350–351.CrossrefMedlineGoogle Scholar7 Khan MN, Joseph G, Khaykin Y, Ziada KM, Wilkoff BL. Delayed lead perforation: a disturbing trend. Pacing Clin Electrophysiol. 2005; 28: 251–253.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Jessel P, Yadava M, Nazer B, Dewland T, Miller J, Stecker E, Bhamidipati C, Song H and Henrikson C (2020) Transvenous management of cardiac implantable electronic device late lead perforation, Journal of Cardiovascular Electrophysiology, 10.1111/jce.14331, 31:2, (521-528), Online publication date: 1-Feb-2020. Herr M, Cottrell J, Garrett H and Weiman D (2020) Erosion of a right ventricular pacer lead into the left chest wall, Surgical Case Reports, 10.1186/s40792-020-00999-3, 6:1, Online publication date: 1-Dec-2020. Zhou X, Ze F, Li D, Wang L, Guo J and Li X (2020) Outcomes of transvenous lead extraction in patients with lead perforation: A single‐center experience, Clinical Cardiology, 10.1002/clc.23327, 43:4, (386-393), Online publication date: 1-Apr-2020. Hirata K, Takahashi T and Nakazato J (2019) Chest Pain and Electrocardiographic Changes in a Patient With a VVI Pacemaker, JAMA Internal Medicine, 10.1001/jamainternmed.2019.3002, 179:10, (1419), Online publication date: 1-Oct-2019. Akbarzadeh M, Mollazadeh R, Sefidbakht S, Shahrzad S and Bahrololoumi Bafruee N (2017) Identification and management of right ventricular perforation using pacemaker and cardioverter-defibrillator leads: A case series and mini review, Journal of Arrhythmia, 10.1016/j.joa.2016.05.005, 33:1, (1-5), Online publication date: 1-Feb-2017. Bautista-Vargas W, Sáenz-Morales L and Rodríguez-Guerrero D (2016) ¿En dónde está el electrodo?, Revista Colombiana de Cardiología, 10.1016/j.rccar.2016.02.001, 23:6, (576-577), Online publication date: 1-Nov-2016. Nichols J, Berger N, Joseph P and Datta D (2015) Subacute Right Ventricle Perforation by Pacemaker Lead Presenting with Left Hemothorax and Shock, Case Reports in Cardiology, 10.1155/2015/983930, 2015, (1-4), . Prestipino F, Nenna A, Casacalenda A and Chello M (2014) Ventricular perforation by pacemaker lead repaired with two hemostatic devices, International Journal of Surgery Case Reports, 10.1016/j.ijscr.2014.10.006, 5:12, (906-908), . HUANG X, FU H, ZHONG L, OSBORN M, ASIRVATHAM S, SINAK L, CAO J, FRIEDMAN P and CHA Y (2014) Outcomes of Lead Revision for Myocardial Perforation After Cardiac Implantable Electronic Device Placement, Journal of Cardiovascular Electrophysiology, 10.1111/jce.12457, 25:10, (1119-1124), Online publication date: 1-Oct-2014. Sharma A, Geelani M and Kumar S (2014) Late cardiac perforation: a persistent risk of cardiac implantable device leads, Indian Journal of Thoracic and Cardiovascular Surgery, 10.1007/s12055-014-0314-9, 30:3, (214-219), Online publication date: 1-Sep-2014. Liang J, Killu A, Osborn M and Jaffe A (2013) Pacemaker lead perforation causing hemopericardium eight years after implantation, Indian Heart Journal, 10.1016/j.ihj.2013.04.009, 65:3, (331-333), Online publication date: 1-May-2013. Koyama S, Itatani K, Kyo S, Aoyama R, Ishiyama T, Harada K and Ono M (2013) Subacute Presentation of Right Ventricular Perforation after Pacemaker Implantation, Annals of Thoracic and Cardiovascular Surgery, 10.5761/atcs.cr.11.01863, 19:1, (73-75), . Negrete A, Cárdenas S, Villarreal K, Montero G, Gil E, Salazar J and Bayuelo D (2012) Perforación tardía del ventrículo derecho con electrodo de fijación activa en el septum y estimulación diafragmática como primera manifestación clínica, Revista Colombiana de Cardiología, 10.1016/S0120-5633(12)70130-4, 19:4, (192-194), Online publication date: 1-Jul-2012. Nakanishi N, Sawada T, Sato R, Yanishi K, Akakabe Y, Nishizawa S, Kuroyanagi A, Tsubakimoto Y, Matsui A, Nakamura T, Shiraishi H, Matsumuro A, Shirayama T and Matsubara H (2009) Spontaneous pericardial hematoma with familial amyloid polyneuropathy, Amyloid, 10.3109/13506120903421751, 16:4, (221-225), Online publication date: 1-Dec-2009. Ferrero-de-Loma-Osorio A, Albors-Martín J, Ruiz-Granell R, Domínguez-Mafé E, Bahamonde-Romano J, Palau-Sampio P and Boix-Garibo R (2009) Delayed Right Ventricular Perforation by a Transvenous Active Fixation Implantable Cardioverter-Defibrillator Lead, Circulation, 10.1161/CIRCULATIONAHA.108.829788, 119:15, (2112-2113), Online publication date: 21-Apr-2009. LAU E, SHANNON H and McKAVANAGH P (2008) Delayed Cardiac Perforation by Defibrillator Lead Placed in the Right Ventricular Outflow Tract Resulting in Massive Pericardial Effusion, Pacing and Clinical Electrophysiology, 10.1111/j.1540-8159.2008.01240.x, 31:12, (1646-1649), Online publication date: 1-Dec-2008. Laborderie J, Barandon L, Ploux S, Deplagne A, Mokrani B, Reuter S, Le Gal F, Jais P, Haissaguerre M, Clementy J and Bordachar P (2008) Management of Subacute and Delayed Right Ventricular Perforation With a Pacing or an Implantable Cardioverter-Defibrillator Lead, The American Journal of Cardiology, 10.1016/j.amjcard.2008.07.025, 102:10, (1352-1355), Online publication date: 1-Nov-2008. Suri R and Keller S (2007) Lead perforation with a small body diameter implantable defibrillator lead, Heart Rhythm, 10.1016/j.hrthm.2007.07.006, 4:9, (1248-1249), Online publication date: 1-Sep-2007. KŘIVAN L, KOZÁK M, VLAŠÍNOVÁ J and SEPŠI M (2007) Right Ventricular Perforation with an ICD Defibrillation Lead Managed by Surgical Revision and Epicardial Leads—Case Reports, Pacing and Clinical Electrophysiology, 10.1111/j.1540-8159.2007.00917.x, 0:0, (071112072846003-???) FISHER J, FOX M, KIM S, GOLDSTEIN D and HARAMATI L (2007) Asymptomatic Anterior Perforation of an ICD Lead into Subcutaneous Tissues, Pacing and Clinical Electrophysiology, 10.1111/j.1540-8159.2007.00918.x, 0:0, (071112072846002-???) SATPATHY R, HEE T, ESTERBROOKS D and MOHIUDDIN S (2007) Delayed Defibrillator Lead Perforation: An Increasing Phenomenon, Pacing and Clinical Electrophysiology, 10.1111/j.1540-8159.2007.00919.x, 0:0, (071112072846004-???) April 10, 2007Vol 115, Issue 14 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.106.669630PMID: 17420357 Originally publishedApril 10, 2007 PDF download Advertisement SubjectsArrhythmiasCardiovascular SurgeryPacemaker
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