Left Minithoracotomy Approach for Repairing Right Ventricular Perforation Caused by Temporary Pacing Catheterization: Two Case Reports

Left Minithoracotomy Approach for Repairing Right Ventricular Perforation Caused by Temporary Pacing Catheterization: Two Case Reports | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Left Minithoracotomy Approach for Repairing Right Ventricular Perforation Caused by Temporary Pacing Catheterization: Two Case Reports Kazuki Noda, Akimasa Morisaki, Yosuke Takahashi, Kenta Nishiya, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6640086/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Dec, 2025 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted 15 You are reading this latest preprint version Abstract Background: Pacing catheter–induced right ventricular (RV) perforation is a rare, life-threatening complication. Its surgical procedure typically involves lead extraction and perforation site repair via a median sternotomy. Recently, a minimally invasive approach via a minithoracotomy has been the alternative feasible approach to cardiac surgery; it reportedly prevents sternotomy-related morbidities or offers favorable cosmetic results. Herein, we present two cases in which a temporary pacing catheter–induced RV perforation was repaired via left minithoractomy. Case 1: An 84-year-old female was admitted with a complete atrioventricular block, which was then treated by temporary pacing catheterization. Two days later, the pacing failed. Computed tomography and echocardiography revealed that the temporary pacing catheter migrated and penetrated the RV apex without pericardial effusion. Subsequently, we repaired the perforation via a left minithoracotomy through the left sixth intercostal space. Intraoperatively, a hematoma was detected on the RV apex, with the penetrated catheter covered by the epicardium. After removing the pacing catheter, we achieved hemostasis by using sheet-type hemostatic agents. Case 2: A 91-year-old female developed a complete atrioventricular block following transcatheter aortic valve implantation. She then underwent temporary pacing catheterization. Two days postoperatively, the pacing failed because the catheter was dislocated, as confirmed by chest X-ray. Computed tomography also revealed RV perforation apparently. Meanwhile, the fixing sutures of the pacing catheter were loose. She then underwent RV repair via a left minithoracotomy in the same fashion as that of case 1. The pacing catheter perforated the RV apex apparently, with bloody pericardial effusion. After removing the pacing catheter percutaneously, we repaired the perforation site through mattress suturing. Conclusionss: Two patients with RV perforation caused by temporary pacing catheterization with stable hemodynamics were successfully treated by a left minithoracotomy. Pacing catheter perforation Right ventricular perforation Minimally invasive cardiac surgery Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Pacing catheter–induced right ventricular (RV) perforation is a rare complication with an incidence of only 0.3–0.8%, but it has been associated with morbidity potentially [ 1 ] . It is commonly treated by surgical repair via a median sternotomy [ 2 ] . However, sternotomy-related morbidities remain a concern, especially in older patients or those at high risk for mediastinitis. Recently, some reports have described surgical repair via a minithoracotomy for permanent pacemaker lead-induced perforation [ 3 , 4 ] . Nevertheless, surgical repair for temporary pacing catheter–induced RV perforation via a left minithoracotomy has been rarely reported. Herein, we present two cases successfully repaired via a left minithoracotomy for subacute RV perforation caused by temporary pacing catheterization. Case presentation Case 1 An 84-year-old female who had a complete atrioventricular block with syncope was admitted to the department of cardiology for pacemaker implantation. Her medical history included diabetes mellitus, hypertension, dyslipidemia, and hepatic cell carcinoma. After admission, a cardiologist inserted a pacing catheter via the right jugular vein temporarily. Two days later, she developed presyncope caused by a pacing failure, but with stable hemodynamics. Electrocardiac monitoring showed an occasional bradycardia (30 beats/minute) that was not improved by controlling the pacing. Computed tomography (CT) and transthoracic echocardiography (TTE) revealed that the temporary pacing catheter migrated and penetrated the RV apex without pericardial effusion (Figure. 1A). Thus, she was diagnosed with RV perforation caused by the migration of the temporary pacing catheter. Three-dimensional CT angiography showed that the penetrated site can be approached directly through the left sixth or seventh intercostal space (Figure. 1B). Hence, we urgently planned to perform a surgical repair through a left minithoracotomy for the perforated RV. Under general anesthesia with a single-lumen endotracheal tube in the supine position, the patient underwent a left minithoracotomy with an approximately 4 cm-long skin incision through the sixth intercostal space. After opening of the pericardium, we noticed a hematoma on the RV apex, with the penetrating catheter totally covered by the epicardium fat (Figure. 2A, 2B). Following the removal of the pacing catheter, we repaired the hematoma site using the TachoSil Tissue Sealing Sheet (CSL Behring LLC, King of Prussia, Pennsylvania, USA) for reinforcement without suturing because the active bleeding was not identified. Immediately after the operation, she was extubated. On postoperative day 3, she underwent permanent leadless pacemaker implantation, and on postoperative day 17, she was discharged with no untoward events. Case 2 A 91-year-old female, who had a medical history of hypertension, dyslipidemia, and lacunar cerebral infarction, was referred to the department of cardiology for a syncope. TTE showed severe aortic valve stenosis, as evidenced by an aortic jet velocity of 4.5 m/s and an aortic valve area of 0.69 cm 2 , indicating the need for surgical intervention. Therefore, the heart valve team performed transcatheter aortic valve replacement using a self-expandable valve. However, she developed a complete atrioventricular block postoperatively; thus, she underwent temporary pacing catheterization via the left jugular vein. After 2 days, the pacing failed according to electrocardiac monitoring, but with stable hemodynamics. Chest X-ray showed that the pacing catheter was dislocated (Figure. 3A and B), and CT revealed that the pacing catheter penetrated the RV apex apparently (Figure. 4). Additionally, the fixing suture of the pacing catheter was loose. We were then consulted for surgical operation for the RV perforation caused by temporary pacing catheterization. Similar to case 1, we performed the surgical repair via a left minithoracotomy. During surgery, the patient was under general anesthesia with a single-lumen endotracheal tube. Then, we approached the RV perforation site through the sixth intercostal space. After opening the pericardium, we found the pacing catheter that perforated the RV apex apparently with slightly bloody pericardial effusion (Figure. 5). We removed the pacing catheter percutaneously and repaired the perforation site with pledgeted mattress sutures for secure hemostasis. After the operation, she was extubated immediately. On postoperative day 4, she underwent permanent pacemaker implantation, and on postoperative day 14, she was discharged uneventfully. Discussion Pacing catheter–induced RV perforation is a potentially life-threatening complication. However, in our cases, the pacing catheter–induced RV perforation was detected solely based on pacing failure, which prompted further investigations without moving the pacing catheter. This is consistent with a previous study reporting that all patients were symptomatic or experienced inappropriate pacing [ 5 ] . Therefore, pacing catheter migration should be considered when pacing failure occurs during a temporary pacing to prevent lethal complications. The lead position should always be confirmed on X-ray before the removal of a pacing catheter, even in the absence of symptoms or pacing failure. Some reports have shown that the predictors of perforation include temporary leads, steroid use within 7 days before pacing catheterization, helical screw leads, RV apical lead positioning, longer fluoroscopy time, low body mass index (< 20 kg/m 2 ), older age, female sex, and concomitant anticoagulation therapy [ 6 , 7 ] . Moreover, a case report suggested that the forward pressure to the free wall location of the lead contributes to perforation [ 8 ] . Risk factors such as temporary lead utilization, advanced age, female sex, low body mass index, and apical lead positioning were observed in our two patients. Additionally, based on our case, insufficient fixation of the catheter, combined with intermittent forward pressures from each cardiac cycle, might have contributed to perforation. The conventional median full-sternotomy is generally performed, especially in cases with tamponade or hemothorax [ 9 ] . This approach provides comprehensive access and direct visualization, making it suitable for complex surgical repairs in unexpected emergency cases. However, the choice of surgical approach depends on factors such as the patient’s condition, the location and extent of the perforation, and associated complications [ 10 ] . The use of a left minithoracotomy approach for permanent pacemaker lead-induced perforation has been reported; this approach can provide access to the apex and allow for the immediate removal of pericardial effusion [ 3 ] . However, the minithoracotomy approach may be unsuitable for cases with unstable hemodynamics, a rightward-shifted heart, or severe adhesions of left lung. In our cases, RV perforation caused by a temporary pacing catether was successfully repaired via a left minithoracotomy. Recently, robotic-assisted repair for right atrial perforation caused by an atrial lead has been reported [ 4 ] . However, there are no reports of robotic repair for RV perforation. Moreover, robotic repair may provide little benefit for RV perforation because the left minithoracotomy approach offers a good operative field close to the heart, allowing for direct and easy repair. Additionally, robotic repair is challenging in the emergent or urgent cases. Therefore, a left minithoractomy approach may serve as a viable alternative to median sternotomy in selected cases, particularly when minimizing surgical invasiveness is a priority. Preoperative CT angiography plays a crucial role in evaluating the RV perforation and the positional relationships between the perforation site and the intercostal spaces, facilitating a precise and safe approach for a left minithoracotomy. Moreover, as demonstrated in Case 1, even when various imaging modalities clearly suggest lead perforation, the lead may actually remain embedded in epicardial fat without active bleeding. In such cases, repair may be achieved using reinforcement with hemostatic materials without the need for suturing. Conclusion Surgical repair for temporary pacing catheter–induced RV perforation via a left minithoracotomy may be safe and feasible for patients with stable hemodynamics. Abbreviations RV right ventricular CT computed tomography TTE transthoracic echocardiography Declarations Ethics approval and consent to participate : This work does not require ethical considerations or approval. Consent for publication : Written informed consent was obtained from the patient for publication of this case report and accompanying images. Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: Not applicable. Authors’ contributions: Writing; K.N., Critical review and revision; K.N., A.M., Final approval of the article; all authors, Accountability for all aspects of the work; all authors. Acknowledgements: We would like to thank Emelda from Enago (www.enago.jp) for the English language review. References Carlson MD, Freedman RA, Levine PA. Lead perforation: incidence in registries. Pacing Clin Electrophysiol. 2008;31:13–5. Nicolardi S, Floris GP, Rocco D, Casali G. Right ventricular and chest wall perforation caused by a permanent pacemaker lead after implantation. Eur J Cardiothorac Surg. 2017;51:188. Uemura H, Yajima S, Sekiya N, Yamazaki S, Satoh A, Tanaka H, et al. Repair of pacemaker lead-induced right ventricular perforation via a left mini-thoracotomy. J Cardiol Cases. 2021;24:307–9. Wang Z, Yuan Z, Li H, Zhang K, Zhang H, Li X, et al. Atrial lead perforation early after device implantation- a case report and literature review. Front Surg. 2024;11:1290574. 10.3389/fsurg.2024.1290574 . Schwerg M, Stockburger M, Schulze C, Bondke H, Poller WC, Lembcke A, et al. Clinical, anatomical, and technical risk factors for postoperative pacemaker or defibrillator lead perforation with particular focus on myocardial thickness. Pacing Clin Electrophysiol. 2014;37:1291–6. Mahapatra S, Bybee KA, Bunch TJ, Espinosa RE, Sinak LJ, McGoon MD, et al. Incidence and predictors of cardiac perforation after permanent pacemaker placement. Heart Rhythm. 2005;2:907–11. Cano O, Andres A, Alonso P, Osca J, Sancho-Tello MJ, Olague J, et al. Incidence and predictors of clinically relevant cardiac perforation associated with systematic implantation of active-fixation pacing and defibrillation leads: a single-centre experience with over 3800 implanted leads. Europace. 2017;19:96–102. Akbarzadeh MA, Mollazadeh R, Sefidbakht S, Shahrzad S, Bahrololoumi Bafruee N. Identification and management of right ventricular perforation using pacemaker and cardioverter-defibrillator leads: A case series and mini review. J Arrhythm. 2017;33:1–5. Refaat MM, Hashash JG, Shalaby AA. Late perforation by cardiac implantable electronic device leads: clinical presentation, diagnostic clues, and management. Clin Cardiol. 2010;33:466–75. Rav Acha M, Rafael A, Keaney JJ, Elitzur Y, Danon A, Shauer A, et al. The management of cardiac implantable electronic device lead perforations: a multicenter study. Europace. 2019;21:937–43. Additional Declarations No competing interests reported. Supplementary Files case1opemovieJTCS.mp4 Cite Share Download PDF Status: Published Journal Publication published 03 Dec, 2025 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted Editorial decision: Revision requested 16 Sep, 2025 Reviews received at journal 16 Jul, 2025 Reviewers agreed at journal 15 Jul, 2025 Reviews received at journal 13 Jul, 2025 Reviews received at journal 10 Jul, 2025 Reviewers agreed at journal 10 Jul, 2025 Reviewers agreed at journal 10 Jul, 2025 Reviewers agreed at journal 10 Jul, 2025 Reviewers agreed at journal 10 Jul, 2025 Reviews received at journal 09 Jul, 2025 Reviewers agreed at journal 09 Jul, 2025 Reviewers invited by journal 09 Jul, 2025 Editor assigned by journal 12 May, 2025 Submission checks completed at journal 12 May, 2025 First submitted to journal 11 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6640086","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":483688761,"identity":"c48aec0d-da56-48b0-85f3-b2d9fc397316","order_by":0,"name":"Kazuki Noda","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBklEQVRIiWNgGAWjYBACCSBmbDCA8hIYLBj4wYwC4rVIMEg2gBgGhLQg8w0OgGg8WiTbjz+TnFHAIMc/I4FN4kGFhLzx+dWJHx4YMMjzix3AqkWaJyFNcoMBg7HEDaCWhDMShttuvN0sAXSY4czZCVi1yDEkHJMEmpm4QSKB2SCxTYJx242zG0BaEgxu49DC/7ANRYv95hlnN//Ap0VaIpkN5DCQFsYHQC2JG/h7t+G1RXLGM2bLGQYSxhJnHjY+APolecYN3m0WCQYSOP0icT794c2ePzZy/O3JBw7+qLCx7e8/u/kmkCHPL41dC0wnAyJ6JBJgIkQD/gOkqB4Fo2AUjIIRAADd6lpRWg0QqgAAAABJRU5ErkJggg==","orcid":"","institution":"Osaka Metropolitan University","correspondingAuthor":true,"prefix":"","firstName":"Kazuki","middleName":"","lastName":"Noda","suffix":""},{"id":483688762,"identity":"b18a293a-8800-473c-b30a-dfa3e7b0cc2c","order_by":1,"name":"Akimasa Morisaki","email":"","orcid":"","institution":"Osaka Metropolitan University","correspondingAuthor":false,"prefix":"","firstName":"Akimasa","middleName":"","lastName":"Morisaki","suffix":""},{"id":483688763,"identity":"c6ffa11b-5714-477a-9e42-6cc929e7b601","order_by":2,"name":"Yosuke Takahashi","email":"","orcid":"","institution":"Osaka Metropolitan University","correspondingAuthor":false,"prefix":"","firstName":"Yosuke","middleName":"","lastName":"Takahashi","suffix":""},{"id":483688764,"identity":"a6dafd9f-09d8-484b-a509-3dceb6010b53","order_by":3,"name":"Kenta Nishiya","email":"","orcid":"","institution":"Osaka Metropolitan University","correspondingAuthor":false,"prefix":"","firstName":"Kenta","middleName":"","lastName":"Nishiya","suffix":""},{"id":483688765,"identity":"935e19f2-6550-40bc-a290-6e67241333ec","order_by":4,"name":"Goki Inno","email":"","orcid":"","institution":"Osaka Metropolitan University","correspondingAuthor":false,"prefix":"","firstName":"Goki","middleName":"","lastName":"Inno","suffix":""},{"id":483688766,"identity":"2050d685-07eb-4cfc-b9e7-eba2356ac33b","order_by":5,"name":"Toshihiko Shibata","email":"","orcid":"","institution":"Osaka Metropolitan University","correspondingAuthor":false,"prefix":"","firstName":"Toshihiko","middleName":"","lastName":"Shibata","suffix":""}],"badges":[],"createdAt":"2025-05-11 14:23:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6640086/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6640086/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13019-025-03730-1","type":"published","date":"2025-12-03T15:58:15+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":86662296,"identity":"fcdc8dc1-76db-4b70-ad02-42f7c831e7e8","added_by":"auto","created_at":"2025-07-14 10:42:31","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":519152,"visible":true,"origin":"","legend":"\u003cp\u003eTransthoracic echocardiography (A) and three-dimensional computed tomography angiography (B) of case 1.\u003c/p\u003e\n\u003cp\u003eThe white arrow indicates penetration of the right ventricular apex by the pacing catheter. White lines outline the external wall and cavity of the right ventricle. The pacing catheter is highlighted in green (B). The white dashed arrow indicates the tip of the pacing catheter between the sixth and seventh intercostal space.\u003c/p\u003e","description":"","filename":"Slide1.png","url":"https://assets-eu.researchsquare.com/files/rs-6640086/v1/7851b7625cfc5eb54f227498.png"},{"id":86662298,"identity":"27e8895f-4945-4fad-a5c9-185564c148bf","added_by":"auto","created_at":"2025-07-14 10:42:31","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":451361,"visible":true,"origin":"","legend":"\u003cp\u003eOperative findings (A) and a schematic illustration (B) of case 1.\u003c/p\u003e\n\u003cp\u003eThe white circle (A) and black arrow (B) indicate the hematoma of the right ventricular apex. RV, right ventricle; LV, left ventricle.\u003c/p\u003e","description":"","filename":"Slide2.png","url":"https://assets-eu.researchsquare.com/files/rs-6640086/v1/970f86c161da00029060e3f7.png"},{"id":86662299,"identity":"3982bfdd-e046-4222-9598-e37d3b5ac15e","added_by":"auto","created_at":"2025-07-14 10:42:31","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":320755,"visible":true,"origin":"","legend":"\u003cp\u003eChest X-ray findings of case 2.\u003c/p\u003e\n\u003cp\u003eBlack arrows indicate the temporary pacing catheter. (A) Before the transposition of the pacing catheter. (B) After the transposition of the pacing catheter.\u003c/p\u003e","description":"","filename":"Slide3.png","url":"https://assets-eu.researchsquare.com/files/rs-6640086/v1/e52e4e7b7825f3d2091f549f.png"},{"id":86662297,"identity":"6dc5b230-14bf-467e-82c4-b9ad934201a0","added_by":"auto","created_at":"2025-07-14 10:42:31","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":214249,"visible":true,"origin":"","legend":"\u003cp\u003eComputed tomography angiography of case 2.\u003c/p\u003e\n\u003cp\u003eThe white arrowhead indicates that the pacing catheter penetrates the right ventricular apex.\u003c/p\u003e","description":"","filename":"Slide4.png","url":"https://assets-eu.researchsquare.com/files/rs-6640086/v1/b6823410ad3476263a45e0ed.png"},{"id":86662301,"identity":"e1de0449-0de8-4b83-a4e3-811dec44a0e5","added_by":"auto","created_at":"2025-07-14 10:42:31","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":537808,"visible":true,"origin":"","legend":"\u003cp\u003eOperative findings of case 2.\u003c/p\u003e\n\u003cp\u003eThe black arrow indicates the site of penetration in the right ventricular apex by the pacing catheter. The white arrow head indicates that the pacing catheter is outside the right ventricle.\u003c/p\u003e","description":"","filename":"Slide5.png","url":"https://assets-eu.researchsquare.com/files/rs-6640086/v1/a837837318e41223db2e83e0.png"},{"id":97723985,"identity":"4ac4472a-5ddd-4d82-a42f-f54ad268b0b6","added_by":"auto","created_at":"2025-12-08 16:10:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2763761,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6640086/v1/e455d723-945e-45b9-a7b5-4a6f7d4b6a97.pdf"},{"id":86662306,"identity":"2341d6fe-82d2-4ffc-94e7-caaac5e7e6e1","added_by":"auto","created_at":"2025-07-14 10:42:32","extension":"mp4","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":12313449,"visible":true,"origin":"","legend":"","description":"","filename":"case1opemovieJTCS.mp4","url":"https://assets-eu.researchsquare.com/files/rs-6640086/v1/830b54b9a41956f4a23ddd4e.mp4"}],"financialInterests":"No competing interests reported.","formattedTitle":"Left Minithoracotomy Approach for Repairing Right Ventricular Perforation Caused by Temporary Pacing Catheterization: Two Case Reports","fulltext":[{"header":"Background","content":"\u003cp\u003ePacing catheter\u0026ndash;induced right ventricular (RV) perforation is a rare complication with an incidence of only 0.3\u0026ndash;0.8%, but it has been associated with morbidity potentially \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. It is commonly treated by surgical repair via a median sternotomy \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. However, sternotomy-related morbidities remain a concern, especially in older patients or those at high risk for mediastinitis. Recently, some reports have described surgical repair via a minithoracotomy for permanent pacemaker lead-induced perforation \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. Nevertheless, surgical repair for temporary pacing catheter\u0026ndash;induced RV perforation via a left minithoracotomy has been rarely reported. Herein, we present two cases successfully repaired via a left minithoracotomy for subacute RV perforation caused by temporary pacing catheterization.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eCase 1\u003c/h2\u003e\u003cp\u003eAn 84-year-old female who had a complete atrioventricular block with syncope was admitted to the department of cardiology for pacemaker implantation. Her medical history included diabetes mellitus, hypertension, dyslipidemia, and hepatic cell carcinoma. After admission, a cardiologist inserted a pacing catheter via the right jugular vein temporarily. Two days later, she developed presyncope caused by a pacing failure, but with stable hemodynamics. Electrocardiac monitoring showed an occasional bradycardia (30 beats/minute) that was not improved by controlling the pacing. Computed tomography (CT) and transthoracic echocardiography (TTE) revealed that the temporary pacing catheter migrated and penetrated the RV apex without pericardial effusion (Figure. 1A). Thus, she was diagnosed with RV perforation caused by the migration of the temporary pacing catheter. Three-dimensional CT angiography showed that the penetrated site can be approached directly through the left sixth or seventh intercostal space (Figure. 1B). Hence, we urgently planned to perform a surgical repair through a left minithoracotomy for the perforated RV.\u003c/p\u003e\u003cp\u003eUnder general anesthesia with a single-lumen endotracheal tube in the supine position, the patient underwent a left minithoracotomy with an approximately 4 cm-long skin incision through the sixth intercostal space. After opening of the pericardium, we noticed a hematoma on the RV apex, with the penetrating catheter totally covered by the epicardium fat (Figure. 2A, 2B). Following the removal of the pacing catheter, we repaired the hematoma site using the TachoSil Tissue Sealing Sheet (CSL Behring LLC, King of Prussia, Pennsylvania, USA) for reinforcement without suturing because the active bleeding was not identified. Immediately after the operation, she was extubated. On postoperative day 3, she underwent permanent leadless pacemaker implantation, and on postoperative day 17, she was discharged with no untoward events.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eCase 2\u003c/h3\u003e\n\u003cp\u003eA 91-year-old female, who had a medical history of hypertension, dyslipidemia, and lacunar cerebral infarction, was referred to the department of cardiology for a syncope. TTE showed severe aortic valve stenosis, as evidenced by an aortic jet velocity of 4.5 m/s and an aortic valve area of 0.69 cm\u003csup\u003e2\u003c/sup\u003e, indicating the need for surgical intervention. Therefore, the heart valve team performed transcatheter aortic valve replacement using a self-expandable valve. However, she developed a complete atrioventricular block postoperatively; thus, she underwent temporary pacing catheterization via the left jugular vein. After 2 days, the pacing failed according to electrocardiac monitoring, but with stable hemodynamics. Chest X-ray showed that the pacing catheter was dislocated (Figure. 3A and B), and CT revealed that the pacing catheter penetrated the RV apex apparently (Figure. 4). Additionally, the fixing suture of the pacing catheter was loose. We were then consulted for surgical operation for the RV perforation caused by temporary pacing catheterization.\u003c/p\u003e\u003cp\u003eSimilar to case 1, we performed the surgical repair via a left minithoracotomy. During surgery, the patient was under general anesthesia with a single-lumen endotracheal tube. Then, we approached the RV perforation site through the sixth intercostal space. After opening the pericardium, we found the pacing catheter that perforated the RV apex apparently with slightly bloody pericardial effusion (Figure. 5). We removed the pacing catheter percutaneously and repaired the perforation site with pledgeted mattress sutures for secure hemostasis. After the operation, she was extubated immediately. On postoperative day 4, she underwent permanent pacemaker implantation, and on postoperative day 14, she was discharged uneventfully.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePacing catheter\u0026ndash;induced RV perforation is a potentially life-threatening complication. However, in our cases, the pacing catheter\u0026ndash;induced RV perforation was detected solely based on pacing failure, which prompted further investigations without moving the pacing catheter. This is consistent with a previous study reporting that all patients were symptomatic or experienced inappropriate pacing \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Therefore, pacing catheter migration should be considered when pacing failure occurs during a temporary pacing to prevent lethal complications. The lead position should always be confirmed on X-ray before the removal of a pacing catheter, even in the absence of symptoms or pacing failure.\u003c/p\u003e\u003cp\u003eSome reports have shown that the predictors of perforation include temporary leads, steroid use within 7 days before pacing catheterization, helical screw leads, RV apical lead positioning, longer fluoroscopy time, low body mass index (\u0026lt;\u0026thinsp;20 kg/m\u003csup\u003e2\u003c/sup\u003e), older age, female sex, and concomitant anticoagulation therapy \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. Moreover, a case report suggested that the forward pressure to the free wall location of the lead contributes to perforation \u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. Risk factors such as temporary lead utilization, advanced age, female sex, low body mass index, and apical lead positioning were observed in our two patients. Additionally, based on our case, insufficient fixation of the catheter, combined with intermittent forward pressures from each cardiac cycle, might have contributed to perforation.\u003c/p\u003e\u003cp\u003eThe conventional median full-sternotomy is generally performed, especially in cases with tamponade or hemothorax \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. This approach provides comprehensive access and direct visualization, making it suitable for complex surgical repairs in unexpected emergency cases. However, the choice of surgical approach depends on factors such as the patient\u0026rsquo;s condition, the location and extent of the perforation, and associated complications \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. The use of a left minithoracotomy approach for permanent pacemaker lead-induced perforation has been reported; this approach can provide access to the apex and allow for the immediate removal of pericardial effusion \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. However, the minithoracotomy approach may be unsuitable for cases with unstable hemodynamics, a rightward-shifted heart, or severe adhesions of left lung. In our cases, RV perforation caused by a temporary pacing catether was successfully repaired via a left minithoracotomy. Recently, robotic-assisted repair for right atrial perforation caused by an atrial lead has been reported \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. However, there are no reports of robotic repair for RV perforation. Moreover, robotic repair may provide little benefit for RV perforation because the left minithoracotomy approach offers a good operative field close to the heart, allowing for direct and easy repair. Additionally, robotic repair is challenging in the emergent or urgent cases. Therefore, a left minithoractomy approach may serve as a viable alternative to median sternotomy in selected cases, particularly when minimizing surgical invasiveness is a priority.\u003c/p\u003e\u003cp\u003ePreoperative CT angiography plays a crucial role in evaluating the RV perforation and the positional relationships between the perforation site and the intercostal spaces, facilitating a precise and safe approach for a left minithoracotomy. Moreover, as demonstrated in Case 1, even when various imaging modalities clearly suggest lead perforation, the lead may actually remain embedded in epicardial fat without active bleeding. In such cases, repair may be achieved using reinforcement with hemostatic materials without the need for suturing.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSurgical repair for temporary pacing catheter\u0026ndash;induced RV perforation via a left minithoracotomy may be safe and feasible for patients with stable hemodynamics.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eright ventricular\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ecomputed tomography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTTE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003etransthoracic echocardiography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e:\u0026nbsp;This work does not require ethical considerations or approval.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e:\u0026nbsp;Written\u0026nbsp;informed consent was obtained from the patient for publication of this case report and accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u003c/strong\u003e Writing; K.N., Critical review and revision; K.N., A.M., Final approval of the article; all authors, Accountability for all aspects of the work; all authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eWe would like to thank Emelda from Enago (www.enago.jp) for the English language review.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCarlson MD, Freedman RA, Levine PA. Lead perforation: incidence in registries. Pacing Clin Electrophysiol. 2008;31:13\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNicolardi S, Floris GP, Rocco D, Casali G. Right ventricular and chest wall perforation caused by a permanent pacemaker lead after implantation. Eur J Cardiothorac Surg. 2017;51:188.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUemura H, Yajima S, Sekiya N, Yamazaki S, Satoh A, Tanaka H, et al. Repair of pacemaker lead-induced right ventricular perforation via a left mini-thoracotomy. J Cardiol Cases. 2021;24:307\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang Z, Yuan Z, Li H, Zhang K, Zhang H, Li X, et al. Atrial lead perforation early after device implantation- a case report and literature review. Front Surg. 2024;11:1290574. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fsurg.2024.1290574\u003c/span\u003e\u003cspan address=\"10.3389/fsurg.2024.1290574\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSchwerg M, Stockburger M, Schulze C, Bondke H, Poller WC, Lembcke A, et al. Clinical, anatomical, and technical risk factors for postoperative pacemaker or defibrillator lead perforation with particular focus on myocardial thickness. Pacing Clin Electrophysiol. 2014;37:1291\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMahapatra S, Bybee KA, Bunch TJ, Espinosa RE, Sinak LJ, McGoon MD, et al. Incidence and predictors of cardiac perforation after permanent pacemaker placement. Heart Rhythm. 2005;2:907\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCano O, Andres A, Alonso P, Osca J, Sancho-Tello MJ, Olague J, et al. Incidence and predictors of clinically relevant cardiac perforation associated with systematic implantation of active-fixation pacing and defibrillation leads: a single-centre experience with over 3800 implanted leads. Europace. 2017;19:96\u0026ndash;102.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAkbarzadeh MA, Mollazadeh R, Sefidbakht S, Shahrzad S, Bahrololoumi Bafruee N. Identification and management of right ventricular perforation using pacemaker and cardioverter-defibrillator leads: A case series and mini review. J Arrhythm. 2017;33:1\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRefaat MM, Hashash JG, Shalaby AA. Late perforation by cardiac implantable electronic device leads: clinical presentation, diagnostic clues, and management. Clin Cardiol. 2010;33:466\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRav Acha M, Rafael A, Keaney JJ, Elitzur Y, Danon A, Shauer A, et al. The management of cardiac implantable electronic device lead perforations: a multicenter study. Europace. 2019;21:937\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pacing catheter perforation, Right ventricular perforation, Minimally invasive cardiac surgery","lastPublishedDoi":"10.21203/rs.3.rs-6640086/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6640086/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Pacing catheter–induced right ventricular (RV) perforation is a rare, life-threatening complication. Its surgical procedure typically involves lead extraction and perforation site repair via a median sternotomy. Recently, a minimally invasive approach via a minithoracotomy has been the alternative feasible approach to cardiac surgery; it reportedly prevents sternotomy-related morbidities or offers favorable cosmetic results. Herein, we present two cases in which a temporary pacing catheter–induced RV perforation was repaired via left minithoractomy.\u003c/p\u003e\n\u003cp\u003eCase 1: An 84-year-old female was admitted with a complete atrioventricular block, which was then treated by temporary pacing catheterization. Two days later, the pacing failed. Computed tomography and echocardiography revealed that the temporary pacing catheter migrated and penetrated the RV apex without pericardial effusion. Subsequently, we repaired the perforation via a left minithoracotomy through the left sixth intercostal space. Intraoperatively, a hematoma was detected on the RV apex, with the penetrated catheter covered by the epicardium. After removing the pacing catheter, we achieved hemostasis by using sheet-type hemostatic agents.\u003c/p\u003e\n\u003cp\u003eCase 2: A 91-year-old female developed a complete atrioventricular block following transcatheter aortic valve implantation. She then underwent temporary pacing catheterization. Two days postoperatively, the pacing failed because the catheter was dislocated, as confirmed by chest X-ray. Computed tomography also revealed RV perforation apparently. Meanwhile, the fixing sutures of the pacing catheter were loose. She then underwent RV repair via a left minithoracotomy in the same fashion as that of case 1. The pacing catheter perforated the RV apex apparently, with bloody pericardial effusion. After removing the pacing catheter percutaneously, we repaired the perforation site through mattress suturing.\u003c/p\u003e\n\u003cp\u003eConclusionss: Two patients with RV perforation caused by temporary pacing catheterization with stable hemodynamics were successfully treated by a left minithoracotomy.\u003c/p\u003e","manuscriptTitle":"Left Minithoracotomy Approach for Repairing Right Ventricular Perforation Caused by Temporary Pacing Catheterization: Two Case Reports","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-14 10:42:27","doi":"10.21203/rs.3.rs-6640086/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-16T20:50:27+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-17T00:41:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"75850712830385063677729509826168259631","date":"2025-07-15T13:59:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-13T17:30:01+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-10T19:49:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"13016193111523652065732696669654723490","date":"2025-07-10T14:19:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"123203705430560997890973370945404646335","date":"2025-07-10T12:09:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"204019250323310146247761982224848421164","date":"2025-07-10T05:44:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"253503386702330581415826907422221344453","date":"2025-07-10T04:55:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-09T17:11:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"226688152749723681071709889919231922707","date":"2025-07-09T16:48:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-09T10:40:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-12T14:16:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-12T14:14:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2025-05-11T14:07:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"87ad9746-3626-4559-abdb-6f9a6c37dec8","owner":[],"postedDate":"July 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-08T16:03:48+00:00","versionOfRecord":{"articleIdentity":"rs-6640086","link":"https://doi.org/10.1186/s13019-025-03730-1","journal":{"identity":"journal-of-cardiothoracic-surgery","isVorOnly":false,"title":"Journal of Cardiothoracic Surgery"},"publishedOn":"2025-12-03 15:58:15","publishedOnDateReadable":"December 3rd, 2025"},"versionCreatedAt":"2025-07-14 10:42:27","video":"","vorDoi":"10.1186/s13019-025-03730-1","vorDoiUrl":"https://doi.org/10.1186/s13019-025-03730-1","workflowStages":[]},"version":"v1","identity":"rs-6640086","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6640086","identity":"rs-6640086","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}