Asian Cardiovasc Thorac Ann 2008;16:183-184
© 2008 Asia Publishing EXchange Ltd
IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY |
Right Ventricular Perforation Induced by Trans Venous Pacing Lead
Cheemalapati Sai Krishna, MCh,
Vedangi Ramesh Babu, MD1,
Kanteti Ram Mohan, DA PDCC1,
Nanda K Panigrahi, DM2,
Palli V Naresh Kumar, MCh
Department of Cardiothoracic Surgery
1 Department of Cardiac Anaesthesia
2 Department of Cardiology, Apollo Heart Institute, Andhra Pradesh, India
For reprint information contact: Cheemalapati Sai Krishna, MCh, Tel: 91 891 272 7272 Ext 526, Fax: 91 891 256 0858, Email: csaikrishna{at}yahoo.com, Department of Cardiothoracic and Vascular Surgery, Apollo Heart Institute, Waltair Main Road, Visakhapatnam 530 002, Andhra Pradesh, India.
A male patient aged 54 years was admitted with unstable angina and evolving inferior wall ST elevation myocardial infarction. An emergency transvenous right ventricular pacing electrode was placed for second degree heart block and the patient was put on ventricular pacing. Coronary angiography revealed triple vessel disease with a thrombus in the mid-portion of the right coronary artery.
The patient was taken up for emergency coronary revascularisation. At pericardiotomy the transvenous pacing electrode had perforated the free wall of the right ventricle (Figure 1
). There was no hemopericardium or active bleeding. The right ventricular perforation was controlled with a pledgetted mattress suture (Figure 2) and the catheter withdrawn as the suture was tightened. Off-pump triple-vessel coronary artery bypass grafting was performed and the patient recovered uneventfully. Though percutaneous intervention was considered, surgery proved to be the right choice as cardiac tamponade could have occurred during withdrawal of the pacing lead.
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Figure 1. Image showing the pacing lead through the perforation in the right ventricle. RV = Right Ventricle, LAD = Left anterior descending artery, LV = Left ventricle.
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Figure 2. Pledgetted suture repair of the perforation in the right ventricle. p = Perforation in free wall of right ventricle.
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Catheter induced perforation of cardiac chambers is a well known entity.1,2 In this instance the complication went un-noticed as the lead appeared to be contained within the cardiac silhouette during coronary arteriography, pacing was still possible and the perforation was sealed by the lead.
High index of suspicion is required for correct diagnosis and tip electrograms would provide definitive evidence.3,4 It is imperative to confirm lead position through tip electrograms to avoid the catastrophic complication of pericardial tamponade in all patients as a protocol.
REFERENCES
- Meyer JA, Millar K. Perforation of the right ventricle by electrode catheters: a review and report of nine cases. Ann Surg. 1968;168(6):1048–60.[Medline]
- Gomes WJ, Buffolo E. Perforation of the right ventricular wall by temporary pacemaker wire. Tex Heart Inst J. 2004;31(4):457[Medline]
- Macdonald J, Kelly D, Waktare J. Value of the unipolar electrogram in the diagnosis of right ventricular perforation following pacemaker implantation. Heart 2005;91(2):228.[Free Full Text]
- Chandan K, Ponde C, Lokhandwala Y, Nandkumar K. Old is gold: tip electrograms to diagnose pacemaker lead perforation. J Cardiovasc Electrophysiol 2002;13(10):1063.[Medline]
