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Simple leads to complex solutions
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  1. Mathew Sheridan1,
  2. Senthil Kirubakaran2
  1. 1Eastbourne District General Hospital, Eastbourne, East Sussex, UK
  2. 2Queen Alexandra Hospital, Portsmouth, UK
  1. Correspondence to Dr Mathew Sheridan, mda04mjs{at}gmail.com

https://doi.org/10.1136/bcr-2014-208869

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    Description

    A 76-year-old woman on warfarin for atrial fibrillation presented for routine pacing check 6 weeks after implantation of a dual-chamber device. She felt weak and generally unwell. The atrial lead was not sensing or pacing at high outputs. A chest X-ray showed the lead had perforated the atrial wall (figure 1). Echocardiography showed no pericardial effusion. International normalised ratio was 2.4.

    Figure 1
    Figure 1

    Chest radiograph 6 weeks after device implantation showing the atrial lead has perforated the atrial wall.

    In light of these findings, urgent lead revision was planned in a centre with cardiothoracic facilities due to the increased risk of pericardial effusion and tamponade.

    Although pacemaker malfunction can be complex, simple non-specialist investigations can elucidate causes and majorly impact management.

    Learning points

    • Simple, systematic investigation of unwell patients (with cardiac devices) before specialist input can majorly inform and impact management.

    • Delayed lead perforation is defined as lead perforation more than 30 days after implantation and has a reported incidence of 0.8%.1

    • Although many cases of lead perforation may be asymptomatic,1 prompt recognition (facilitated by simple investigation) may prevent resultant pericardial effusion, tamponade and fistulae.1

    Reference

    1. ↵
      1. Khoueiry G,
      2. Lakhani M,
      3. Abi Rafeh N, et al
      . Right coronary artery fistula as a result of delayed right atrial perforation by a passive fixation lead. Circ Arrhythm Electrophysiol 2012;5:e46–7. doi:10.1161/CIRCEP.111.970376
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    Footnotes

    • Competing interests None.

    • Patient consent Obtained.

    • Provenance and peer review Not commissioned; externally peer reviewed.