Delayed Right Atrial Lead Perforation: Discrepancy Between Preoperative Findings and Surgical Inspection

An 87-year-old man presented with chest pain and pericardial effusion two years after dual-chamber implantable cardioverter-defibrillator implantation. Computed tomography suggested delayed right atrial lead perforation, although the pacing threshold was initially unchanged. Five days later, the threshold increased from 0.875 to 2.0 V/0.4 ms, raising concern for progression of the perforation. However, surgical exploration revealed hemorrhagic pericardial effusion without active bleeding and only minimal protrusion of the screw tip. The right atrial wall was reinforced with felt and sutured without lead extraction or repositioning. The pacing threshold subsequently returned to baseline, and no further lead intervention was required.