Right heart perforation by pacemaker leads

Cardiac pacing is a proven therapy of cardiac conduction disturbances and an effective treatment modality in many cardiac arrhythmias. Implantable cardiac defibrillators (ICDs) are particularly beneficial for selected groups of patients with a history of severe ventricular arrhythmias or at a high risk of sudden cardiac death. Despite their potential lifesaving properties, both pacemakers and ICDs are associated with a number of complications. The most frequent include pneumothorax; myocardial perforation; lead malposition, displacement or fracture due to excessive manipulation of the device by the patient (Twiddler’s syndrome) [1]. Another group of complications comprises infections: from the pacemaker pocket to bacterial endocarditis with its origin on leads or the tricuspid valve, failure of leads to pace and/or sense appropriately, erosion of the pacemaker site or its leads, and thrombotic events with the most frequently observed subclavian vein thrombosis [2]. In the era of massive anticoagulation and antiplatelet therapy bleeding complications are not uncommon, either. The rate of acute complications from device implantation is acceptable and ranges from 3% to 7% [1-3], depending on the patient group. Nevertheless the problem seems important when account is taken of the fact that permanent devices are implanted in over 250,000 patients a year in the United States alone. The paper entitled "Heart perforation in patients with permanent cardiac pacing personal observations" presents cases of lead perforation treated in a single medical centre, with well-described diagnostic and treatment procedures. Results of this paper are largely consistent with literature findings, but there nevertheless are some interesting differences, as outlined below [4]. Studies have reported overall lead perforation rates after pacemaker implantation to be 0.1-0.8%, and after ICD placement 0.6-5.2% [3]. The highest reported rate of perforation, based on autopsy, was 27% for patients with atrial leads [5]. Authors of the present paper report a very low incidence rate (0.09%), which is probably related to the engagement of a highly experienced medical team [4]. There are no uniform classifications accounting for the complication. It may be acute (developing during the first 24 h after implantation), subacute (up to 1 month) or chronic. Another classification system divides perforations into early (occurring during the first month after placement) and late. In the present paper, the authors report on cases of subacute and delayed lead perforations. Most of them (5/6 patients) were symptomatic, but in all of them pacing or sensing failure was present [4]. Excessive loop or tension on the lead will predispose to a forward movement through the thinner right atrial or ventricular wall, particularly the apex. Corresponding author: Prof. Janina Stępińska MD, PhD Intensive Cardiac Therapy Clinic Institute of Cardiology 42 Alpejska 04-628 Warsaw Poland E-mail: [email protected] Editorial