General Cardiology Fellow Dearborn, Michigan, United States
Disclosure(s):
Ahmad El-Gammal, MD: No financial relationships to disclose
Background: Delayed lead perforation is a rare but potentially fatal complication of implantable cardioverter-defibrillators (ICDs), defined as occurring more than 30 days after implantation, with an incidence of 0.4-2.0%. Presentations range from asymptomatic lead malfunction to tamponade, which highlights the need for timely recognition and surveillance
Methods: A 53-year-old male with a history of polysubstance use, non-ischemic cardiomyopathy (ejection fraction 15-20%) with biventricular ICD implanted two years prior to presentation, and LV thrombus presented with dyspnea on exertion and fatigue. He was admitted for decompensated heart failure and treated with intravenous diuresis. He had an echocardiogram outpatient 3 days prior to presentation which showed an EF of 10% with no pericardial effusion. On presentation, CXR confirmed marked cardiomegaly with an enlarged cardiac silhouette. During hospitalization, he initially showed improvement, but then became hypotensive, developed multiorgan damage with shock liver (AST 12,000), acute kidney injury (Cr 2.1) and lactic acidosis (8.0) . Echocardiography revealed a new large pericardial effusion and cardiac tamponade
Outcome: Emergent pericardiocentesis removed 1500 mL of hemorrhagic fluid, and a pericardial drain was placed with transient hemodynamic improvement. However, in the ensuing hours, persistent high-volume output (300 cc/hr) from the pericardial drain prompted further investigation of the etiology of the effusion. A repeat bedside echocardiography showed marked improvement in the pericardial effusion, however the patient was becoming hypotensive and tachycardic. A CT of the chest demonstrated perforation of the right ventricular lead through the apical myocardium into the pericardial space. The patient then underwent emergent surgical repair of the right ventricular apex with subsequent clinical stabilization
Conclusion: Lead perforation typically occurs within 24 hours of lead insertion. Delayed lead perforation occurring years after implantation is very rare, with only few case reports published. This case highlights the importance of recognizing delayed lead perforation as a time-sensitive cause of cardiac tamponade and shock that may require multimodality imaging.
