Lead Explantation Late After Atrial Perforation ALEXANDRE }. TRIGANO and THIERRY CAUS* From the Department of Cardiology, Centre Hospitalier Universitaire Nord, and the *Department of Cardiac Surgery, Centre Hospitalier Universitaire La Timone, University of Marseille, School of Medicine, Marseille, France TRIGANO, A.J., ET AL.: Lead Explantation Late After Atrial Perforation. Tbis report describes the case of a patient in wbom atrial perforation witb penetration of tbe tboracic wall was diagnosed 2 years after tbe implantation of an Accufix lead. Despite tbis complication, atrial detection in the bipolar mode and ventricular pacing were normal. Digital fluoroscopy detected a fracture witb extrusion of a short segment of tbe retention wire. Tbe rupture of tbe retention wire might have been the result, but was not the cause of tbe perforation. (PACE 1996; 19:1268-1269) atrial perforation, Accufix^'^ atrial lead Introduction Lead removal long after severe atrial perforation has rarely been reported. We report a case that occurred 2 years after placement of an Accufix^"^ lead (model, 330-801, Telectronics Pacing Systems, Inc., Englewood, CO, USA). Perforation was associated with a fracture of the J shaped retention wire. Case Report A 45-year-old woman was referred to our cardiac pacing department for elective removal of a model 330-801 Accufix lead. This lead had been inserted in the lateral atrial wall 2 years earlier, in conjunction with placement of a dual chamber pacemaker for symptomatic complete auriculoventricular block. The first implantation procedure had been performed at the referring center, via the right subclavian vein. A passive fixation lead was inserted in the ventricular apex and an ELA Medical pulse generator (model 6005, ELA Medical, Inc., Le Plessis-Robinson, France) was used. Ten days after this intervention, the patient was readmitted for left hemothoracic drainage. Recovery and foUow-up were uneventful. Following the voluntary recall issued hy the manufacturer, digital fluoroscopy was performed at the referring center and revealed a broken retention wire with extrusion of a distal short segment. The patient Address for reprints: Alexandre (. Trigano, M.D., Centre Hospitalier Nord, 13915 Marseille, Cedex 20. France. Fax: 33-91968001, Received September 15, 1995; revision October 9, 1995; accepted February 6,1996. 1268 was sent to us at that time. Upon admission, the patient was asymptomatic and electrocardiography demonstrated permanent ventricular pacing following atrial activity detected in the hipolar mode. Atrial activity could not be detected at the highest sensitivity level in the unipolar detection mode, and atrial capture was not achieved even at the highest energy level. The ventricular pacing threshold was 1.25 V/0.40 ms. A standard chest roentgenogram showed the ventricular lead course to be normal. The atrial lead was inserted in the high lateral atrial wall. Its J shape was maintained, most of the proximal electrode was intracardiac, but the distal electrode extended through the atrial wall into the right hemithorax. The helix was fully extended, and there was no pleural effusion or pulmonary abnormality. Repeat digital fluoroscopy confirmed that a short segment of the retention wire had extruded through the insulation near the proximal electrode. The bare wire appeared to be inside the right atrium and close to the lateral wall. Echocardiography showed no pericardial effusion hut suggested that the tip of the atrial lead had perforated the lateral atrial wall. Right angiocardiography confirmed atrial perforation but there was no pericardial or thoracic opacification (Eig. 1). Open surgery was undertaken to remove the lead and repair the atrium. After sternotomy and suspension of the pericardium, visual examination showed that the atrial lead had perforated the atrial wall, the pericardium, and the right lung and penetrated the thoracic wall at the level of' the fifth intercostal space. The lead was extracted through a pursestring suture and replaced with an endocardial active lead inserted in the right atrial appendage. August 1996 PACE, Vol. 19 LEAD EXPLANTATION AFTER ATRIAL PERFORATION Figure 1. Right angiocardiography (frontal view) showing the atria! lead extending through the high lateral atrial wall into the right hemithorax. The angiographic catheter was passed from the femoral vein into the right atrium. Postoperative inspection of the Accufix lead confirmed the extrusion of a short segment of the retention wire. Discussion A few cases involving atrial wall perforation by a pacing lead have been described previously. Emergency thoracotomy or pericardiocentesis were usually performed within hours to days after implantation. Late diagnosis or long-term followup before reintervention is uncommon. Late occurrence of a perforation has only been reported as the result of electrode migration following lead rupture. In one such report, reoperation was performed 5 months after the implantation, when complete rupture of the ventricular lead led to perforation of the atrial wall, pericardium, and pleura by the free end. ^ In our case, although no operative or immediate postoperative data are available, it is likely that perforation occurred during or soon after implantation. Thus, this report demonstrates that cardiac perforation can be discovered late if recovery from implantation procedure is uneventful. It is only possible to speculate as to the mechanism underlying lead perforation in our patient. Several risk factors can be attributed to the implantation technique and lead design, including overscrewing, distal stiffness, and penetration depth of the helix, Recent publications have reported acute atrial perforation^'^ or acute pericarditis following implantation of the Telectronics model 330-801 lead. It should be emphasized that the latter complication developed after placement in the lateral and anterolateral wall.* The fact that pacing function was normal despite severe atrial perforation with penetration of the thoracic wall can be explained by the electrode configuration. The distance between the electrodes, 17 mm followed by the helix course extension, 1.5 ± 0.2 mm, made a thoracic intrusion possible, with a maintained atrial activity detection using the 8-mm long, proximal electrode. Atrial perforation was associated with a J shaped retention wire fracture. This latter complication has been well documented.^ The perforation may have contributed to the J wire fracture, due to a scissoring effect caused by the difference in stress on the extracardiac and intracardiac portions of the lead. Explantation was required due to the risk of additional atrial injury hy the extruded ] wire segment. Perforation increased this risk by bringing the bare segment of wire closer to the atrial wall. References 1. Deutsch LS, Dang H, Brandon JC, et al. Percutaneous removal of transvenous pacing lead perforating the heart, pericardium and pleura. Am J Roentgenol 1991; 156:471-473. 2. Glikson M, Von Feldt LK, Suman VJ, et al. Clinical surveillance of an active fixation bipolar, polyurethane insulated pacing lead. PACE 1994; 17:1399-1404. 3. Van Acker R, Dielen D, Eycken M. An exceptional FACE. Vol. 19 August 1996 case of the helix of an active fixation lead perforating the right atrial wall, resulting in bleeding from a pericardial artery and cardiac tamponade. Eur JCPE 1993; 1:67-69. Creene TO, Portnow AS, Huang SKS. Acute pericarditis resulting from an endocardial active fixation screw-in atrial lead. PACE 1994; 17:21-25. Parsonnet V. The retention wire fix. PACE 1995; 18;955-957. 1269