Cardiac Rhythm Management
Articles Articles 2011 August

Section Editor Commentary - Subacute Right Ventricular Pacemaker Lead Perforation: Often talked about in consent forms but rarely seen

DOI: 10.19102/icrm.2011.020806

Brian Olshansky, MD, FHRS, FACC, FAHA

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Perforation or, inadvertent malpositioning, of endocardial permanent pacemaker (or implant table defibrillator) leads may be an uncommon, yet serious and important, complication1,2 that, when recognized, can usually be treated effectively before disaster necessarily strikes. These issues are highlighted clearly in the case report in this issue of the journal by Welch et al.3 As the authors show, identification of lead migration and its treatment may require clues found on clinical presentation after implant and on diagnostic testing.

While uncommon, suspicions should be raised when there is a new, or increasing, pleural or pericardial effusion, changes in the QRS or P wave pacing morphologies, unusual positioning on chest radiograph (with changes suggesting migration), or increasing pacing threshold (or anodal unipolar pacing only).4 Clues, although non-specific, include pleuritic chest pain, dyspnea, diaphragmatic chest wall46 or abdominal stimulation7 hiccoughs,8 new unexplained chest hematoma,9 or new pericardial friction rub. Other conditions can mimic cardiac perforation10 or be confused with it.11

The diagnosis may be evident by findings noted on chest radiographs, echocardiography, or electrocardiography. The presence of a right bundle branch block during “right ventricular” pacing with specific morphologies may be diagnostic for perforation or help rule it out.1214 Even home monitoring systems may help with the diagnosis.15 In some cases, computed tomography (CT) scanning is helpful to secure the diagnosis as has been reported as far back as the 1980s.1619 Data from CT scanning suggest that asymptomatic lead perforation is much more common than expected.

Leads can be positioned correctly but perforate and migrate over time. As Welch et al. point out, this appears to be rare.3 Eventually, a lead may perforate the heart causing tamponade and end up in the pleural space,20 through the chest wall21 (near the breast).22 It may end up in subcutaneous tissue,23 perforating the rib24 or the mitral valve,25 or piercing multiple organs.26 It may even cause pneumopericardium.27

Perforation may be due, in part, to lead type, excess tension on the lead, malpositioning or specific patient characteristics. In some cases, even with a well-positioned lead at the time of implant, migration with slow perforation may occur due to stiffness or properties of the lead28,29 (rather uncommon now) or to the delicacy of the tissue into which the lead is placed or both. Older women may be at highest risk of perforation and lead migration. In the Mayo Clinic experience, presumed perforations (not necessary subacute or with lead migrations) were associated with effusion s in 1.2% of implants. In a multivariate model, use of a temporary pacemaker, helical screw leads, and steroids were associated with effusions.30

It is probably not unusual for endocardial leads to perforate at time of implantation. If the lead is recognized, pulled back, and repositioned, serious short- or long-term complications rarely ensue. It is not completely clear how many implanted endocardial leads have perforated as they are not always associated with symptoms of signs.3133 Some still function well without long-term complication.

As we had reported in a case referred to us for further management, inadvertent endocardial pacemaker lead positioning can occur mistakenly via structures without even entering the cardiac chambers.34

A pacemaker system implant is generally a simple and straightforward procedure. Despite this, complications can occur at almost every conceivable step of the way. As Welch and colleagues discuss, ideally the complication of perforation would be best avoided. Unfortunately, this problem is likely to be with us for quite some time. As Welch et al. further discuss, sometimes an innovative approach may be required to correct the problem once it occurs to avoid a disastrous consequence.3 Treatments vary from simply pulling the lead back to an open surgical approach depending on the clinical presentation and clinical judgment.35 Here,3 video-assisted thoracoscopic surgery proved effective. Being that it is not always possible with this complication, the best that can be done is be aware of the problem, make an early diagnosis, and treat promptly.

Brian Olshansky, MD, FHRS, FACC, FAHA
Professor of Medicine
Cardiac Electrophysiology
University of Iowa Hospitals
Iowa City, Iowa


  1. Ellenbogen KA, Wood MA, Shepard RK. Delayed complications following pacemaker implantation. Pacing Clin Electrophysiol 2002;25:1155–1158. [CrossRef] [PubMed]
  2. Sterlinski M, Przybylski A, Maciag A, et al. Subacute cardiac perforations associated with active fixation leads. Europace 2009;11:206–212. [CrossRef] [PubMed]
  3. Welch AR, Yadav P, Lingle K, et al. Subacute right ventricular pacemaker lead perforation: often talked about in consent forms but rarely seen. Cardiac Rhythm Management 2011.
  4. Occhetta E, Bortnik M, Marino P. Ventricular capture by anodal pacemaker stimulation. Europace 2006;8:385–387. [CrossRef] [PubMed]
  5. Jedrzejowski D, Majewski JP, Lelakowski J. Pacemaker lead perforation presenting with left chest wall stimulation. Europace 2011. [CrossRef] [PubMed]
  6. Greenberg S, Lawton J, Chen J. Images in cardiovascular medicine. Right ventricular lead perforation presenting as left chest wall muscle stimulation. Circulation 2005;111:e451–452. [CrossRef] [PubMed]
  7. Green SM. Pacemaker electrode perforation of the myocardium: an unusual etiology for recurrent abdominal pain. Am J Emerg Med 1989;7:180–184. [PubMed]
  8. Celik T, Kose S, Bugan B, Iyisoy A, Akgun V, Cingoz F. Hiccup as a result of late lead perforation: report of two cases and review of the literature. Europace 2009;11:963–965. [CrossRef] [PubMed]
  9. Laborderie J, Bordachar P, Reuter S, Clementy J. Myocardial pacing lead perforation revealed by mammary hematoma next to the device pocket. J Cardiovasc Electrophysiol 2007;18:338. [PubMed]
  10. Krishnan MN, Luqman N, Nair R, et al. Recurrent postcardiac injury syndrome mimicking cardiac perforation following transvenous pacing: An unusual presentation. Pacing Clin Electrophysiol 2006;29:1312–1314. [CrossRef] [PubMed]
  11. Peddi P, Vodnala D, Kalavakunta JK, Thakur RK. Acute chest pain: Acute coronary syndrome versus lead perforation: A case report. Int Arch Med 2010;3:13. [CrossRef] [PubMed]
  12. Coman JA, Trohman RG. Incidence and electrocardiographic localization of safe right bundle branch block configurations during permanent ventricular pacing. Am J Cardiol 1995;76:781–784. [CrossRef] [PubMed]
  13. Yang YN, Yin WH, Young MS. Safe right bundle branch block pattern during permanent right ventricular pacing. J Electrocardiol 2003;36:67–71. [CrossRef] [PubMed]
  14. Okmen E, Erdinler I, Oguz E, et al. An electrocardiographic algorithm for determining the location of pacemaker electrode in patients with right bundle branch block configuration during permanent ventricular pacing. Angiology 2006;57:623–630. [CrossRef] [PubMed]
  15. Migliore F, Leoni L, Torregrossa G, et al. Asymptomatic right ventricular perforation by an implantable cardioverter defibrillator lead detected by home monitoring system. J Electrocardiol 2010;43:673–675. [CrossRef] [PubMed]
  16. Sussman SK, Chiles C, Cooper C, Lowe JE. CT demonstration of myocardial perforation by a pacemaker lead. J Comput Assist Tomogr 1986;10:670–672. [PubMed]
  17. Irwin JM, Greer GS, Lowe JE, German LD, Gilbert MR. Atrial lead perforation: a case report. Pacing Clin Electrophysiol 1987;10:1378–1381. [CrossRef] [PubMed]
  18. Dilling-Boer D, Ector H, Willems R, Heidbuchel H. Pericardial effusion and right-sided pneumothorax resulting from an atrial active-fixation lead. Europace 2003;5:419–423. [CrossRef] [PubMed]
  19. Henrikson CA, Leng CT, Yuh DD, Brinker JA. Computed tomography to assess possible cardiac lead perforation. Pacing Clin Electrophysiol 2006;29:509–511. [CrossRef] [PubMed]
  20. Boriani G, Biffi M, Martignani C. Uneventful right ventricular perforation with displacement of a pacing lead into the left thorax. J Cardiothorac Vasc Anesth 2008;22:423–425. [CrossRef] [PubMed]
  21. Amara W, Cymbalista M, Sergent J. Delayed right ventricular perforation with a pacemaker lead into subcutaneous tissues. Arch Cardiovasc Dis 2010;103:53–54. [CrossRef] [PubMed]
  22. Sanoussi A, El Nakadi B, Lardinois I, De Bruyne Y, Joris M. Late right ventricular perforation after permanent pacemaker implantation: how far can the lead go? Pacing Clin Electrophysiol 2005;28:723–725. [CrossRef] [PubMed]
  23. Fisher JD, Fox M, Kim SG, Goldstein D, Haramati LB. Asymptomatic anterior perforation of an ICD lead into subcutaneous tissues. Pacing Clin Electrophysiol 2008;31:7–9. [CrossRef] [PubMed]
  24. Singhal S, Cooper JM, Cheung AT, Acker MA. Images in cardiovascular medicine. Rib perforation from a right ventricular pacemaker lead. Circulation 2007;115:e391–392. [CrossRef] [PubMed]
  25. Konings TC, Koolbergen DR, Bouma BJ, Groenink M, Mulder BJ. Iatrogenic perforation of the posterior mitral valve leaflet: a rare complication of pacemaker lead placement. J Am Soc Echocardiogr 2008;21:512, e515–517. [CrossRef] [PubMed]
  26. Madershahian N, Wippermann J, Wahlers T. The bite of the lead: multiorgan perforation by an active-fixation permanent pacemaker lead. Interact Cardiovasc Thorac Surg 2010;11:93–94. [CrossRef] [PubMed]
  27. Matsushita A, Komiya T, Tamura N, Sakaguchi G. Pneumopericardium caused by a permanent endocardial pacing lead. Interact Cardiovasc Thorac Surg 2008;7:1127–1128. [CrossRef] [PubMed]
  28. Trigano AJ, Caus T. Lead explantation late after atrial perforation. Pacing Clin Electrophysiol 1996;19:1268–1269. [CrossRef] [PubMed]
  29. Mera F, Walter P, Langberg J. Protrusion without fracture of the Accufix atrial “J” lead retention wire. J Cardiovasc Electrophysiol 1997;8:1062–1064. [CrossRef] [PubMed]
  30. Mahapatra S, Bybee KA, Bunch TJ, et al. Incidence and predictors of cardiac perforation after permanent pacemaker placement. Heart Rhythm 2005;2:907–911. [CrossRef] [PubMed]
  31. Akyol A, Aydin A, Erdinler I, Oguz E. Late perforation of the heart, pericardium, and diaphragm by an active-fixation ventricular lead. Pacing Clin Electrophysiol 2005;28:350–351. [CrossRef] [PubMed]
  32. Selcuk H, Selcuk MT, Maden O, et al. Uncomplicated heart and lung perforation by a displaced ventricular pacemaker lead: a case report. Pacing Clin Electrophysiol 2006;29:429–430. [CrossRef] [PubMed]
  33. Hirschl DA, Jain VR, Spindola-Franco H, Gross JN, Haramati LB. Prevalence and characterization of asymptomatic pacemaker and ICD lead perforation on CT. Pacing Clin Electrophysiol 2007;30:28–32. [CrossRef] [PubMed]
  34. Berenji K, Drazner MH, Rothermel BA, Hill JA. Does load-induced ventricular hypertrophy progress to systolic heart failure? Am J Physiol Heart Circ Physiol 2005;289:H8–H16. [CrossRef] [PubMed]
  35. Geyfman V, Storm RH, Lico SC, Oren JWt. Cardiac tamponade as complication of active-fixation atrial lead perforations: proposed mechanism and management algorithm. Pacing Clin Electrophysiol 2007;30:498–501. [CrossRef] [PubMed]