Clinical, Anatomical, and Technical Risk Factors for Postoperative Pacemaker or Defibrillator Lead Perforation with Particular Focus on Myocardial Thickness MARIUS SCHWERG, M.D.,* MARTIN STOCKBURGER, M.D.,† CHRISTOPH SCHULZE, M.D.,* HANSJ ¨ URGEN BONDKE, M.D.,* WOLFRAM C. POLLER, M.D.,* ALEXANDER LEMBCKE, M.D.,‡ and CHRISTOPH MELZER, M.D.* *Department of Cardiology and Angiology, Charit´ e – Universit¨ atsmedizin, Berlin, Germany; †Department of Cardiology, Havelland Kliniken, Nauen, Germany; and ‡Department of Radiology, Charit´ e – Universit¨ atsmedizin, Berlin, Germany Background: Postoperative lead perforation is a life-threatening complication of cardiac pacing. Identification of precipitating factors for this serious complication may help to anticipate a specific risk profile and to minimize the incidence. Methods: We conducted a retrospective tertiary referral center analysis to clarify clinical, anatomical, and technical characteristics related to pacemaker (PM) and cardioverter/defibrillator lead perforation. We examined the baseline characteristics and the symptoms. In a subgroup, we investigated the myocardial thickness on contrast-enhanced cardiac computed tomography. Results: We enrolled 26 patients. Female gender appears to put patients at slightly increased risk for lead perforation. In a majority active fixation leads were used. Symptoms occurred in 72%. Pericardial effusion and tamponade were present in 38% and 19%, respectively. Sensing was compromised in 65%. A high pacing threshold or exit block occurred in 92%. Myocardial thickness did not differ between patients with or without perforation. In 96%, the perforation was treated by transvenous withdrawal. Conclusion: Chest pain, phrenic stimulation, bad sensing, or exit block early after PM implantation must prompt radiological and echocardiographic evaluation. A missing pericardial effusion particularly late after implantation does not rule out a perforation. Especially active fixating leads have a higher risk of perforation. With cardiac surgery in standby transvenous withdrawal is a safe way to treat lead perforation. (PACE 2014; 37:1291–1296) pacemaker, cardioverter/defibrillator, lead perforation, risk factors Introduction Pacemaker (PM) or implantable cardiover- ter/defibrillator (ICD) lead perforation is a rare but potentially life-threatening complication of device-based antibradycardia or antitachycardia treatment. The reported prevalence of lead per- forations is between 0.1–0.8% for PMs and 0.6– 5.2% for ICD. 1–5 In addition, lead perforation causes symptoms in many patients, but may also occur asymptomatically. The prevalence of lead Conflict of interest: None declared. Address for reprints: Marius Schwerg, M.D., Medizinische Klinik f ¨ ur Kardiologie und Angiologie, Charit´ e – Univer- sit¨ atsmedizin Berlin, Charit´ eplatz 1, D – 10117 Berlin, Germany. Fax: 49-30-450-513-932; e-mail: marius.schwerg@charite.de Received January 14, 2014; revised April 2, 2014; accepted April 28, 2014. doi: 10.1111/pace.12431 perforations in computed tomography (CT) scans executed out of other reasons is stated 15% for atrial and 6% for ventricular leads. 6 These data must be interpreted with caution. Due to beam hardening artifacts, the precise locating of the lead tip is difficult. Moreover, the clinical significance of a deeply implanted fixation helix with demonstrable transmyocardial penetration, but without symptoms or electrical abnormalities can be questioned. Published information on risk factors for lead perforation is scarce and predominantly derived from case reports. The identification of precipitat- ing factors for this serious complication may help to anticipate a specific risk profile and to minimize the incidence. Therefore, we conducted this retro- spective tertiary referral center analysis to clarify clinical, anatomical, and technical characteristics related to PM or ICD lead perforation. Espe- cially, whether the thickness of the ventricular myocardium is a risk factor for perforation was of interest. ©2014 Wiley Periodicals, Inc. PACE, Vol. 37 October 2014 1291