Late pacemaker lead tip perforation documented by chest CT

Late cardiac perforation by a right ventricular (RV) pacemaker lead may be a challenge to diagnose. Echocardiography often will not adequately demonstrate lead tip migration, but chest computed tomography (CT) readily identifies the lead and tip location. A patient presented one month after dual-chamber pacemaker implantation with fever, sepsis and failure of RV pacer lead capture. Echocardiography demonstrated vegetations on the RV lead and a pericardial effusion, but the lead tip location could not be identified. CT identified the tip as having migrated through the pericardium into the anterior mediastinum. These complimentary echo and CT findings helped make a diagnosis and direct patient therapy.