Chronic ventricular lead perforation: Expect the unexpected
The present case appears in the journal Clinical Case Reports.

A 61‐year‐old female had undergone a dual chamber pacemaker for high‐degree atrioventricular block with exertional dyspnoea with a dual chamber pacemaker incorporating an active fixation lead to the RV apex and a passive lead to the right atrial appendage.

Two months prior to her presentation, she had received a new RV lead, placed to the right ventricular outflow tract (RVOT; Medtronic Capsurefix Novus 5076) due to an increase in her chronic RV lead threshold (1.75 V at 1 ms) and impedance value (increased from 650 ohms six months previously to 740 ohms).

She subsequently complained of intermittent chest pains and dyspnoea and was referred to our institution for further investigation. Despite this, given her clinical presentation and unexplained symptoms, the suspicion remained that the RVOT lead may have perforated through the myocardium. To investigate this further, a contrast‐enhanced ECG‐gated cardiac CT scan was performed.

This revealed normal siting of the new RVOT lead but the unexpected finding of myocardial perforation as a result of the chronic RV apical lead (14 years old lead). The case was discussed at a multi‐disciplinary meeting, and a consensus reached for the perforated lead to be extracted. Following a discussion with the patient, it was decided to extract both her atrial and RVOT lead to enable the implantation of a fully MRI compatible device.

The newly sited RV lead was removed with traction alone but a 14 Fr laser sheath was needed to extract both the chronically implanted RV and atrial lead in a hybrid lab without complication. A new dual chamber system was placed, and the patient was discharged home. Upon review in clinic, her symptoms had completely resolved.

Key Clinical Message
- A high index of suspicion is needed to diagnose a chronic right ventricular lead perforation.

- They should be suspected in patients who develop breathlessness and have a sudden change in pacing parameters.

- Contrast‐enhanced CT provides high diagnostic accuracy.

- They can often be extracted percutaneously and rarely require surgical intervention.

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