A Transvenous Pacing Lead's Journey Leading to Perforation and Hematothorax

Recognition of lead-related complications after cardiac implantable electronic device implantation is challenging. An 86-year-old woman with a cardiac resynchronization therapy pacemaker (CRT-P) presented with recurrent nonspecific symptoms, including pulse-synchronous abdominal pain and dyspnea, over 3 emergency department visits. Right ventricular lead perforation went undiagnosed until significant hemothorax developed. A review of electrocardiographic (ECG) and chest X-ray images from earlier visits revealed that lead perforation could have been diagnosed earlier. This case underscores the diagnostic challenges of CIED complications, especially in patients with nonspecific symptoms. Key findings, such as ECG morphology changes and atypical lead position on X-ray, were missed because of limited knowledge of pacemaker-ECG interpretation and inattentional blindness. Lead perforation may occur several weeks after cardiac implantable electronic device implantation. In CRT patients, a predominantly positive stimulated QRS complex in lead V₁ indicates possible loss of right ventricular capture as a possible sign of perforation.