Images in Emergency Medicine
Article Outline
An 86-year-old woman was admitted to the hospital with chest pain lasting for 1 day. Five weeks ago in an external hospital, a 2 chamber-pacemaker system had been implanted because of a sick sinus syndrome. It was reported that the implantation procedure had been unproblematic.
Clinical examination showed an age-related normal physical state. The pacemaker pocket was bland, without any signs of infection. Laboratory analysis results, including the levels of troponin, creatine kinase, D-dimers, and peripheral blood cell count, were found to be normal.
Pacemaker interrogation revealed an ineffective pacing and insufficient sensing of the ventricular lead.
The chest radiograph (Figure) showed the ventricular pacemaker lead tip lying close to the left thoracic wall, without any signs of pneumothorax or hemothorax. Using echocardiography pericardial effusion, cardiac tamponade or a perforation of the tricuspid valve or the interventricular septum could be excluded.
Figure.
Chest radiograph posterior-anterior. Arrow showing the displaced ventricular electrode. Used with permission of Manja Bock, MD, Department of Medicine/Cardiology, Heart Center, Dresden University of Technology, Fetscherstr. Dresden, Germany.
Diagnosis
Perforation of the right ventricle and lung parenchyma by a pacemaker lead
The lead was surgically removed and a new passive ventricular electrode was inserted. There was no evidence of bleeding into the pericardial space, and no further complications occurred. Pacemaker interrogation, chest radiograph, and echocardiography the day after the operation showed no problems.
The present case shows an extraordinary incident of an injury caused by a pacemaker lead perforation 5 weeks after the implantation. Dislocations as obvious as in that patient occur only rarely. Even more unexpected is the fact that neither a pericardial effusion nor a pleural effusion was observed.
In patients with implanted pacemakers and defibrillators, perforation of a lead should always be considered as a possible cause of recently developed chest pain, although it is a rare complication. Usually, cardiac tamponade because of perforation caused by a lead occurs shortly after implantation. Few cases report a subacute or delayed (>1 month after procedure) perforation.1 Clinically, patients present with chest pain, dyspnea, or convulsion of the chest wall muscles or with even more severe symptoms caused by pneumothorax, hematothorax, or pericardial effusions.
In most cases, dislocations through the myocardium but with subepicardial location are difficult to diagnose from a radiograph. If standard techniques do not yield a definitive diagnosis, computed tomography for locating the leads is necessary.2
References
PII: S0196-0644(07)00295-8
doi:10.1016/j.annemergmed.2007.02.024
© 2007 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
