Delayed Lead Perforation: A Disturbing Trend MOHAMMED N. KHAN, GEORGE JOSEPH, YAARIV KHAYKIN, KHALED M. ZIADA, and BRUCE L. WILKOFF From the Cleveland Clinic Foundation, Department of Cardiology, Cleveland, Ohio KHAN, M.N., ET AL.: Delayed Lead Perforation: A Disturbing Trend. Background: Delayed lead perforation (occurring more than 1 month after implantation) is a rare complication. Its pathophysiology and optimal management are currently unclear. Methods: Three cases of delayed lead perforation (6–10 month) were identified in patients with low- profile active fixation leads. Results: All cases presented in a subacute fashion with pleuritic chest pain with confirmatory chest x-ray and device interrogation. Given the potential complications of a perforated lead, all cases had the lead extracted under TEE observation with cardiac surgery backup in the operating room. All patients tolerated extraction without complication. Conclusion: Based on these cases, we recommend a management scheme for patients who present with delayed lead perforation. (PACE 2005; 28:251–253) lead perforation, pacemaker extraction, pericardium Introduction Lead perforation in either the right atrium or the right ventricle is an uncommon event, with published rates of 0.1–0.8% for pacemakers and 0.6–5.2% in ICDs, 1-4 with the majority of lead perforations cited in published reports occurring within 1 month after implantation. We report three cases of delayed lead perforation diagnosed at our institution over 1 year. Patient 1 A 26-year-old female with vasodepressor syn- cope successfully treated with a permanent dual- chambered pacemaker with Medtronic right atrial lead with extendable/retractable screwing (model no. 5076) implanted 10 months before presented to the emergency room for pleuritic right-sided chest pain. A chest x-ray was obtained (Fig. 1). A follow-up chest x-ray 2 days later showed that the right atrial lead was on the right heart border and had changed orientation from the previous exam- ination, indicating movement of the lead into the pericardium or pleural space and development of a small right-sided pleural effusion (Fig. 2). With cardiothoracic backup, the right atrial lead was removed by traction on a locking stylet after retraction of the active fixation screw un- der surveillance by transesophageal echocardiog- raphy. No complications were observed and a new right atrial active fixation lead was placed on the right atrial septum. Address for reprints: Bruce L. Wilkoff, Cleveland Clinic Foun- dation, Department of Cardiology, Desk F15, 9500 Euclid Avenue, Cleveland, OH 44195. Fax: 216-444-4428; e-mail: wilkofb@ccf.org Received November 26, 2004; accepted November 29, 2004. Patient 2 A 71-year-old male with ischemic cardiomy- opathy had a single-chambered ICD implanted for an episode of ventricular tachycardia 5 years be- fore presentation. Eight months before presenta- tion, a right atrial lead was implanted (Medtronic 5076) with a generator replacement. He pre- sented to clinic complaining pleuritic right-sided chest pain with occasional radiation to the back. Chest x-ray showed pacemaker lead perforation into the pericardium. The atrial lead was removed in the operating room with cardiac surgery backup. The atrial lead was extracted with liberator lock- ing stylet and telescoping steel extraction sheaths under TEE observation. A new lead was implanted on the septal wall of the right atrial wall without complication. Patient 3 An 84-year-old male with a dual-chambered pacemaker implanted 6 months previously for si- nus node dysfunction was incidentally found to have a nonfunctioning right ventricular lead (St. Jude model no. 1488T) on routine pacemaker in- terrogation. A chest x-ray showed migration of the RV lead, including the proximal electrode, beyond the cardiac silhouette into the left thorax from the right ventricular apical site. Because of the potential complications caused by the active fixation screw in the left thorax, the patient was taken to the operating room for re- moval of the ventricular lead with cardiac surgery backup. Initially, the right ventricular lead fix- ation screw was retracted. Then, the right ven- tricular lead was extracted with a standard stylet and gentle traction under fluoroscopic guidance and TEE observation. The ventricular port was plugged. PACE, Vol. 28 March 2005 251