Leadless pacemaker implantation after delayed atrial lead perforation and battery depletion: a case report

Delayed lead perforation is a rare complication of cardiac implantable electronic device (CIED). Clinical presentations range from completely asymptomatic to pericardial tamponade. Surgical lead extraction is recommended and transvenous lead extraction (TLE) with surgical backup is an alternative method.

A male with paroxysmal atrial fibrillation and sick sinus syndrome implanted a dual-chamber pacemaker with two passive fixation lead. He was on oral anticoagulants and played golf for almost 1 h every day after implantation. However, he complained of thoracic stabbing in the sternal manubrium with abnormal findings on pacemaker interrogation. Imaging confirmed the perforated atrial electrode with lead tip protrusion from the pericardium adjacent to the inferior wall of the main right pulmonary artery, but without pericardial effusion. Lead removal by TLE with surgical support was suggested, but he refused. Given the stable conditions, conservative treatment was chosen in the absence of complications during a follow-up period of 14 years. Then ventricular lead failure and battery depletion appeared and a leadless pacemaker was implanted.

Chest pain in CIED with abnormal electrical parameters, especially ongoing treatment with anticoagulants and regular physical activity, should always raise suspicion of lead perforation. A conservative strategy may be appropriate and feasible for those in the absence of perforation-related complications. For patients with noninfectious abandoned leads and battery depletion after CIED, leadless pacemaker may be an alternative approach according to patient and provider preferences.