Right ventricular lead perforation revealed by diaphragmatic stimulation
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CE - MEDICAL ILLUSTRATION
Right ventricular lead perforation revealed by diaphragmatic stimulation Damien Nguyen1 · Thomas Nguyen1 · Alexandre Almorad1 · Eva De Keyzer1 Received: 26 July 2020 / Accepted: 1 September 2020 © Società Italiana di Medicina Interna (SIMI) 2020
Abstract Pacemaker implantation can be complicated by ventricular perforation. We present a case of diaphragmatic stimulation induced by right ventricular pacemaker lead perforation.
Introduction A 92-year-old woman presented to the outpatient clinic for acute chest pain starting 3 days after her single lead pacemaker implantation performed 2 weeks earlier for paroxysmal Mobitz II AV-block. Past medical history included hypertension, aortic stenosis and left bundle branch block. She was taking aspirin, losartan and pantoprazole. She was apyretic with a blood pressure of 179/85 mmHg and oxygen saturation of 96% on ambient air. Physical examination showed rhythmic contraction of the diaphragm (Supplementary Video 1). Echocardiography showed reduced LVEF estimated at 35–40% with mild pericardial effusion. The pacemaker lead seemed to project beyond the right ventricle (RV) apex. The EKG showed sinusal rhythm with a known left bundle branch block and no pacing necessary at that time. Chest CT confirmed that the pacemaker perforated the RV apex and extended to the sixth rib (Fig. 1a).
After placement of a new lead on the RV septum, the perforating lead was removed by simple traction under fluoroscopic guidance in the catheterization lab with surgical backup and under close echocardiographic monitoring. The patient was discharged home thereafter with a chest X-Ray showing good lead placement (Fig. 1b) and resolution of the diaphragmatic contractions. Right ventricle perforation is a rare complication of pacemaker implantation. It can result in life threatening consequences such as loss of capture, cardiac tamponade or hemopneumothorax [1]. This case highlights that muscular contraction following pacemaker implantation can be a rare clinical sign of right ventricle perforation but it can also be seen in lead dislodgement and phrenic stimulation with CRT [2–4]. Even without pacemaker interrogation, echocardiography or chest CT, the diagnosis could be suspected on the basis of physical examination alone.
Electronic supplementary material The online version of this article (https://doi.org/10.1007/s11739-020-02490-1) contains supplementary material, which is available to authorized users. * Damien Nguyen [email protected] 1
Cardiology, Brugmann University Hospital, Place A. Van Gehuchten 4, 1020 Bruxelles, Belgium
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Internal and Emergency Medicine
Fig. 1 a Chest CT showing the pacemaker’s lead perforating the RV apex and extending to the sixth rib. b Chest X-Ray showing good lead placement after replacement
Compliance with ethical standards Conflict of interest The author(s) declare that they have no conflict of interest. Statement of human and animal rights All procedures followed were in accordance with the
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