The New England Journal of MedicinePacemaker-Lead Dislodgement and Cardiac Perforation

Pacemaker-Lead Dislodgement: Clinical Presentation, Diagnosis, and Management Strategies

A 96-year-old woman experienced pleuritic chest pain four days after the implantation of a single-chamber transvenous pacemaker for complete heart block. The diagnostic workup revealed pacemaker-lead dislodgement with cardiac perforation, necessitating an urgent percutaneous lead revision. This case stresses the importance of prompt recognition and intervention in pacemaker-related complications to prevent severe outcomes.

Key Points:

• Patient Presentation:
  • A 96-year-old woman presented with pleuritic chest pain 4 days post-pacemaker implantation.
  • Vital signs: blood pressure 100/60 mm Hg, heart rate 40 bpm.
• Electrocardiogram Findings:
  • Complete heart block with an atrial rate of 84 bpm.
  • Junctional escape with right bundle-branch block and a rate of 42 bpm.
  • Pacing spikes observed without ventricular capture.
• Imaging Findings:
  • Chest Radiograph:
    • Tip of the right ventricular lead positioned over the left mid-hemithorax.
  • CT Scan:
    • Pacing lead tip traversing the right ventricle and ending in the left pleural space.
    • Moderate pleural effusion on the left side.
    • Absence of pneumothorax or pericardial effusion.
• Diagnosis:
  • Pacemaker-lead dislodgement with cardiac perforation.
• Clinical Implications:
  • Patients with pacemaker-lead dislodgement may present with chest pain, dyspnea, syncope, or symptoms indicative of cardiac tamponade or pneumothorax.
  • Timely diagnosis and intervention are critical to manage complications effectively.
• Management:
  • Urgent percutaneous lead revision performed with a cardiothoracic surgical team on standby.
  • No complications during the procedure.
  • Patient discharged home 3 days post-presentation.

The reported incidence of cardiac device lead perforation ranges from 0.1% to 0.8% for pacemaker leads and from 0.6% to 5.2% for ICD leads. (JACC Clinical Electrophysiology)

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