Delayed cardiac tamponade resulting from left ventricular free wall perforation caused by a right ventricular septal...

A 70-year-old man underwent dual-chamber pacemaker implantation for symptomatic tachycardia-bradycardia syndrome. The right ventricular (RV) lead was screwed into the RV high septum with a nondeflectable delivery catheter. Two months after implantation, the RV lead perforated through the left ventricular free wall (LVFW) and was identified via computed tomography. The patient underwent open chest surgery. The RV lead was extracted, and a new lead was reinserted at the RV apex after suturing the perforated wounds. Intraoperatively, the extracted lead perforated LVFW beside the first diagonal branch of the left anterior descending artery through the RV septum and the left intraventricular wall instead of the LV cavity. These findings support that the bloody pericardial effusion due to LV perforation in this case originated from RV venous blood but not LV arterial blood and resulted in cardiac perforation of the oozing type instead of the blowout type. The patient was discharged on day 15 post operation, and the patient's situation has been uneventful for a year.

This is a rare case of delayed cardiac tamponade from left ventricular (LV) free wall perforation by a right ventricular (RV) septal lead involving both the RV septum and left intraventricular wall. Appropriate lead management and anatomical understanding are necessary to avoid such complications. If LV free wall perforation and cardiac tamponade are noted, an open surgical procedure for lead removal should be considered as the preferred therapeutic option.