Management of Inadvertent Pacemaker Lead Misplacement: Sometimes Less May Be More

Introduction

The incidence of pacemaker implantation in the United States continues to rise.¹ While pacemaker implantation is generally a well-tolerated procedure, varying complications of differing degrees of severity have been well documented, occurring in 3-7% of patients.^2-3 The most common acute complications include lead dislodgement, pneumothorax, and perforation. Right atrial (RA) and right ventricular (RV) lead perforation is well documented; however, cases of venous perforations appear rare. In this case, we report a case of superior vena cava perforation in an elderly woman diagnosed 10 days after device implantation.

Case Description

The patient is an 89-year-old woman with a past medical history significant for hypertension, hyperlipidemia, and hypothyroidism who presented to an outside hospital with symptoms of dyspnea on exertion and fatigue. She was found to be in complete heart block and underwent left upper chest dual-chamber pacemaker implantation. She was subsequently discharged home; however, she noted that her symptoms of shortness of breath did not significantly improve. She also developed a new cough with clear productive mucus. She returned to the outside facility where a chest x-ray demonstrated a right-sided pleural effusion (Figures 1 and 2), and a computed tomography (CT) scan of the chest was performed that demonstrated findings concerning for extravascular course of the right atrial lead accompanied by hemothorax (Figure 3, Video 1, and Video 2). The patient was subsequently transferred to our facility for further care. 

Upon arrival to our facility, the patient was afebrile, saturating 95% on room air, and hemodynamically stable. She appeared overall comfortable on exam with decreased air movement in her right lower lung fields. She continued to endorse stable shortness of breath, worse with exertion, as well as persistent new onset cough. The chest CT from the outside facility was reviewed and appeared to demonstrate extravascular placement of her right atrial lead essentially exiting through the superior vena cava (SVC) near the junction of the right and left brachiocephalic veins, and subsequently coursing inferiorly and posteriorly in the mediastinum. Her dual-chamber pacemaker had an atrial lead with tined fixation and a right ventricular lead that was tined as well. Of note, the patient’s atrial lead had been turned off and her device programmed VVIR at the outside facility after suspected right atrial lead perforation was noted and no capture was observed upon interrogation. We performed another device interrogation after her right atrial lead was programmed on in DDD mode. With inhibition of pacing, she appeared to be in sinus rhythm with complete heart block with a narrow escape rhythm in the 30s (Figures 4 and 5). Her right atrial lead had no evidence of capture despite pacing at high output (Figure 6). However, the right atrial lead was appropriately sensing and when programmed DDD, it was noted to appropriately track sinus rhythm (Figure 7). Her device was reprogrammed DDD 50-110 bpm. A multidisciplinary discussion involving the cardiothoracic surgery service as well as the radiology service was pursued prior to discussing possible treatment options with the patient and her family. Namely, treatment options included consideration for lead extraction versus a more conservative approach with observation alone for the lead and thoracentesis and drainage of her hemothorax in order to improve her symptoms. Given her advanced age, tined lead, and the location of perforation being within the SVC, the risks of lead extraction (including significant hemorrhage and possible SVC tear) appeared high. Furthermore, the lead appeared to be sensing appropriately and she had no apparent evidence of sinus node dysfunction, which minimized the need for atrial pacing. After an extensive discussion with the patient and her family, the decision was made to proceed with a more conservative approach with observation alone. The interventional radiology service was consulted, and thoracentesis was performed the following day with aspiration of 750 mL of sanguineous fluid. Following thoracentesis, she noted a significant improvement in her shortness of breath. She was observed for another 24 hours, and a subsequent chest x-ray prior to discharge demonstrated a small right-sided residual pleural effusion. A follow-up chest x-ray performed two weeks after discharge was notable for a stable residual right-sided effusion. Clinically, she continues to report gradual improvement in her shortness of breath and cough.

Discussion

Pacemaker lead perforation is a rare complication of pacemaker implantation, occurring in 0.3-1.0% of device implantations.^2,3 The most common symptoms of lead perforation include pleuritic chest pain and hypotension.⁴ However, SVC perforation appears to be quite rare and may present differently. Bogachev-Prokophiev et al described a case of SVC perforation that occurred after several lead revisions and was heralded only by a mild fever, with evidence of a right-sided hemothorax on CXR and loss of atrial capture on device interrogation.⁵ In the present case, the patient had no signs of chest pain and was hemodynamically stable. Rather, she developed shortness of breath and a new cough likely related to the hemothorax. While lead revision is often performed in the event of right atrial or ventricular perforation without the need for subsequent surgical intervention, there is little documented experience with lead extraction and repositioning for transvenous perforation without concomitant surgical intervention.⁴ Given the presence of a tined lead traversing the SVC, which had been in place for 10 days, we were concerned with inducing a tear of the SVC with subsequent lead removal, which would have severe if not fatal consequences. 

After a discussion of the risks and benefits of management options, our patient elected to proceed more conservatively with observation alone.⁵ 

Conclusion

Cardiac perforation during pacemaker implantation is a rare complication. Perforation of the SVC appears less common than right atrial or right ventricular perforation, and may have an atypical presentation. While the typical symptoms of chest pain or hypotension are often seen with right atrial or ventricular perforation, the patient described here presented as hemodynamically stable with symptoms of shortness of breath and new cough. Chest CT appears to be the test of choice for diagnosis. While surgically-assisted lead revision has been described, and taking into account the immediate need for revision, the risks associated with revision, and the patient’s preference, observation alone in select cases may be reasonable. 

The clinical videos featured here are also available at the following links: Video 1 and Video 2

Disclosures: Dr. Wertz has no conflicts of interest to report regarding the content herein.  

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