110 Copyright © 2021 Asian Society of Cardiovascular Imaging INTRODUCTION Although uncommon, cardiac device implantations can lead to complications. Delayed cardiac perforation due to cardiac de- vices is rare, with the reported incidence of cardiac device lead perforation ranging between 0.1% to 0.8% for pacemaker leads and from 0.6% to 5.2% for implantable cardiac defbrillators [1]. We report a rare case of delayed cardiac perforation that pro- gressed to cardiac tamponade that initially presented as loss of pacemaker lead capture. CASE REPORT A 50-year-old female with a single, active-fxation lead per- manent pacemaker (PPM) that had been placed for third-de- gree atrioventricular dissociation approximately one-year prior presented to our center with complains of lethargy, dyspnea, and reduced efort tolerance. Te only medical history was hy- pertension, and she was not on any antiplatelets or anticoagu- lants. She did not report any conditions that would predispose her to bleeding tendencies, including chronic liver or renal dis- ease, or those requiring long-term steroid use. She reported worsening symptoms over the past 6 months, but that symp- toms had become even worse in the 2 weeks prior to presenta- tion. Her vital signs on arrival were a pulse rate of 120 beats/min- ute, blood pressure of 98/75 mm Hg, oxygen saturation of 94% on room air, and a respiratory rate of 22/minute. Examination revealed sof heart sounds with no audible murmurs and bilat- eral crepitations in the bases of the lungs. Tere was evidence of high jugular venous pressure. Home monitoring by her cardiac device showed a gradual increase in ventricular lead threshold (Table 1). However, the lead impedance had remained stable throughout that period. Electrocardiogram revealed absence of pacing spikes and third- degree atrioventricular dissociation. Her chest radiograph dem- onstrated cardiomegaly but no obvious lead displacement (Fig. 1). cc Tis is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by- nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduc- tion in any medium, provided the original work is properly cited. CVIA A Unique Case of Non-Capture of Permanent Pacemaker Lead: Delayed Lead Perforation and Cardiac Tamponade Raja Ezman Faridz Raja Shariff, Lim Chiao Wen, Rizmy Najme Khir, Khairul Shafiq Ibrahim, Sazzli Kasim Universiti Teknologi MARA (UiTM) Sungai Buloh, Malaysia Received: April 13, 2021 Revised: May 23, 2021 Accepted: May 24, 2021 Corresponding author Raja Ezman Faridz Raja Shariff, MBChB, MRCP Universiti Teknologi MARA (UiTM) Sungai Buloh Jalan Hospital, Sungai Buloh, Selangor 47000, Malaysia Tel: 60361265000 Fax: 60361265224 E-mail: rajaezman@gmail.com We report a rare case of delayed cardiac perforation that progressed to cardiac tamponade and initially presented as loss of pacemaker lead capture. A 50-year-old female with a single- lead permanent pacemaker for third-degree atrioventricular dissociation presented with leth- argy, dyspnea, and reduced effort tolerance. Home monitoring by her cardiac device and an electrocardiogram performed on arrival showed loss of capture. Transthoracic echocardiogram revealed cardiac tamponade requiring urgent pericardiocentesis, revealing hemorrhagic ef- fusion. Delayed perforation of her device leads was suspected, even though neither CT nor cardiac MRI revealed contrast leakage or displaced lead position. Cardiac perforation follow- ing device implantation is rare. This case is unique as it highlights an extreme presentation in which delayed perforation led to gradual accumulation progressing to tamponade and loss of device capture, both of which resolved following emergency pericardiocentesis. The main treatment of suspected lead perforation remains revision of leads, although evidence to support either a percutaneous or surgical approach remain debatable. Key words Cardiology · Device · Echocardiography · Pericardial · Cardiac tamponade. pISSN 2508-707X / eISSN 2508-7088 Cardiovasc Imaging Asia 2021;5(3):110-113 https://doi.org/10.22468/cvia.2021.00157 CASE REPORT