Double Whammy: A case report of two iatrogenic cardiac perforations in the same patient

Double Whammy: A case report of two iatrogenic cardiac perforations in the same patient | 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 Double Whammy: A case report of two iatrogenic cardiac perforations in the same patient Shannon Thenagaran, Vivian Cheah, Chua Chen Chen, David Tang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8049595/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Cardiac perforation is an uncommon but potentially fatal complication of pacemaker lead placement and pericardiocentesis. We report the case of a 61-year-old woman who sustained two distinct iatrogenic right ventricular perforations, the first following temporary endocavitary pacemaker (TPM) insertion and the second during rescue echocardiography-guided pericardiocentesis performed for cardiac tamponade after initially presented with symptomatic bradycardia secondary to complete heart block. Emergency surgery via median sternotomy revealed both perforations, which were repaired with pledgeted sutures. Her postoperative recovery was uneventful, and a permanent pacemaker was implanted prior to discharge. This case highlights the rare occurrence of sequential iatrogenic cardiac perforations in a single patient and underscores the importance of vigilance, timely recognition of pacing complications, and multidisciplinary management to prevent fatal outcomes. Cardiothoracic Surgery Cardiac & Cardiovascular Systems cardiac perforation iatrogenic interventional cardiology cardiothoracic surgery pacemaker pericardiocentesis Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Cardiac perforation is a rare but serious complication of pacemaker lead placement, with potentially fatal consequences if not recognized promptly. The reported incidence varies between 0.1–1% for permanent pacemaker implantation and can reach up to 10% for temporary pacing leads, particularly via femoral access due to limited control of lead direction.¹⁻³ While the complication is uncommon, its outcomes can be catastrophic, especially when associated with cardiac tamponade or hemodynamic collapse. We present a unique case of double iatrogenic right ventricular perforation in a patient who first sustained injury following temporary pacemaker (TPM) insertion and subsequently during echocardiography-guided pericardiocentesis. The case highlights diagnostic challenges, clinical decision-making in managing suspected lead perforation, and lessons for procedural safety. Summary figure Timeline of critical events. -3 days Onset of dizziness and fatigue 0 Presentation to hospital - Diagnosis of complete heart block made via ECG - ECHO showed mildly dilated LA & LV, with no other abnormality detected - Admitted to CCU + 6 h Developed multiple episodes of short-run VF + 7 h Temporary endocavitary pacemaker (TPM) inserted via femoral approach Post procedure ECHO showed TPM lead within RV and circumferential pericardial effusion 0.5-0.7cm + 7 h - +10 days Awaiting emergency funding approval for permanent pacemaker insertion. Monitored in CCU, haemodynamically stable, daily ECGs and serial CXRs done ECHO repeated on Day 3 and 7 showing small stable pericardial effusion Intermittent failure to capture pacing, lead repositioning on Day 4 + 10 days Haemodynamic collapse Bedside ECHO showed massive pericardial effusion (> 3cm) with RA & RV collapse indicating cardiac tamponade 1st attempt at rescue echo-guided pericardiocentesis - Continuous drainage of blood from pericardial catheter - Catheter spigoted - Bubble study showed catheter within the RV 2nd attempt at rescue echo-guided pericardiocentesis successful, bubble study confirms catheter placement within pericardial space Urgent surgical referral, taken to theatre - Median sternotomy - Intraoperative findings confirm 2 separate RV perforations - Both repaired with pledgeted sutures - Epicardial pacing leads placed + 10 days - +17 days Postoperatively haemodynamically stable on epicardial pacing No abnormalities detected on postoperative ECHO Surgical drains removed + 17 days Epicardial leads removed and permanent pacemaker inserted + 19 days Discharge from hospital Case presentation A 61-year-old woman with a background of hypertension, dyslipidaemia, and type II diabetes mellitus presented to our centre with a three-day history of dizziness and fatigue consistent with symptomatic bradycardia. Physical examination was unremarkable. Electrocardiography confirmed complete heart block. Echocardiography revealed mild dilatation of the left atrium and ventricle, with no pericardial effusion. She was admitted to the coronary care unit (CCU) for monitoring. Following several short runs of ventricular fibrillation, a temporary endocavitary pacemaker (TPM) was inserted via the right femoral vein. Initial pacing parameters included a capture threshold of 1.0 V at 0.5 ms, impedance of 600 Ω, and pacing rate of 80 bpm, achieving satisfactory capture and sensing. Post-procedure echocardiography demonstrated the TPM lead within the right ventricle and a small circumferential pericardial effusion (0.5–0.7 cm), which was managed conservatively. The patient remained in hospital while awaiting emergency funding approval for a permanent pacemaker. During this period, she was haemodynamically stable but had intermittent episodes of loss of capture, prompting one lead repositioning attempt on day 4, after which pacing parameters normalized. Daily ECGs were performed, and echocardiography was repeated on days 3 and 7, showing stable small effusion without chamber collapse. Serial chest X-rays confirmed appropriate lead position and no pneumothorax. On day 10 post-TPM insertion, she experienced sudden hemodynamic collapse. Bedside echocardiography revealed a massive pericardial effusion (> 3 cm) with right atrial and right ventricular collapse, consistent with cardiac tamponade. Emergency echocardiography-guided pericardiocentesis via subcostal approach yielded continuous drainage of blood. A bubble study confirmed the pericardial catheter tip within the right ventricle, indicating cardiac perforation. The catheter was spigoted, and a second attempt at pericardiocentesis successfully placed a catheter within the pericardial space, draining 400 mL of blood. The patient was urgently referred for surgical management. Intraoperative, transoesophageal echocardiography (TOE) in the operating theatre showed the pericardial catheter within the RV (Fig. 1 ) with the TPM lead not visualised. A median sternotomy was performed to gain access to the heart. Operative findings revealed the tip of the pacing lead protruding out from the RV and the first pericardial catheter seen piercing the RV (Fig. 2 ). The second pericardial catheter was within the pericardial space. The pericardial catheters and the TPM lead were removed and the RV perforations were repaired with pledgeted Prolene 3/0 sutures (Figs. 3 & 4). Standard epicardial pacing leads were placed prior to chest closure and the patient was admitted to the Cardiac Intensive Care Unit (CICU) postoperatively. Her postoperative course was uneventful. Echocardiography showed no residual effusion, and pacing thresholds remained satisfactory. Epicardial leads were removed on day 7, and a permanent pacemaker was implanted the same day. She was discharged two days later in stable condition with no complications. Discussion The rising number of cardiac interventions has naturally led to a proportional increase in iatrogenic cardiac injuries due to the growing procedural volume and complexity of patients undergoing such interventions. 4 , 5 Cardiac perforation during temporary pacemaker insertion occurs in up to 10% of cases and is more common when the femoral route is used, due to reduced control of lead trajectory and higher risk of wall penetration. 3 , 6 Pericardiocentesis, although lifesaving, carries a small but definite risk of myocardial puncture, particularly in emergent or technically challenging settings, with reported incidences of < 1% . 8 This case is remarkable in that both complications, TPM-related perforation and pericardiocentesis-induced perforation, occurred sequentially in the same patient. Failure to capture and new or enlarging pericardial effusion following TPM placement are early indicators of lead perforation. 9 In this patient, intermittent capture failure and persistent small effusion might have signalled an evolving perforation. Regular echocardiography and vigilant clinical correlation are essential, as even mild effusions can progress rapidly to tamponade. Early involvement of cardiothoracic surgery is advised when there is evidence of lead perforation or haemodynamic instability. Surgical exploration via median sternotomy and open repair is warranted in cases of persistent haemorrhage with haemodynamic instability, rapid progression of pericardial effusion, or if closed pericardiocentesis fails. 10 Perforations may be repaired with sutures, patch-and-glue, or a combination of the two with or without the use of extracorporeal circulation and cardioplegic arrest. 11 Conclusion Cardiac perforation is a rare but life-threatening complication of both pacemaker implantation and pericardiocentesis. For this devastating complication to occur twice in the same patient is both remarkable and instructive. This case underscores the importance of early recognition of lead perforation and careful management of iatrogenic cardiac injuries. When faced with unexplained pericardial effusion or pacing abnormalities, clinicians should maintain a high index of suspicion and escalate promptly for echocardiographic evaluation and surgical consultation. Previous studies have shown that when a patient sustains an iatrogenic injury, they are statistically more likely to experience another. 12 Whether this arises from suboptimal operator performance, overzealous attempts to rectify the initial problem, or simply the inherent risks of medical intervention, the lesson remains clear: vigilance and humility are essential in the pursuit of patient safety. Medicine is, after all, a human endeavour and to err is human. If we are to prevent such injuries, they must be studied and reported openly, not to assign blame, but to foster learning and improvement. Eliminating iatrogenic harm requires both technical precision and a culture of transparency that allows practitioners to examine mistakes without fear, ensuring that every complication serves as a catalyst for safer care. Declarations Funding None to declare Acknowledgements None Statement of consent The authors confirm that written informed consent for submission and publication of this case report, including images and associated text, has been obtained in-line with COPE guidelines. References Mahapatra S, Bybee KA, Bunch TJ, Espinosa RE, Sinak LJ, McGoon MD et al (2005) Incidence and predictors of cardiac perforation after permanent pacemaker placement. Heart Rhythm 2(9):907–911 Laborderie J, Barandon L, Ploux S, Deplagne A, Mokrani B, Reuter S et al (2008) Management of subacute and delayed right ventricular perforation with a pacing or an implantable cardioverter-defibrillator lead. Am J Cardiol 102(10):1352–1355 Timperley J, Leeson P, Mitchell AR, Betts T (eds) (2018) Oxford Specialist Handbook of Pacemakers and ICDs, 2nd edn. Oxford University Press Kumar R (2017) Management of Accidental and Iatrogenic Foreign Body Injuries to Heart- Case Series. Journal of Clinical and Diagnostic Research Banaszewski M, Stępińska J (2012) Right heart perforation by pacemaker leads. Arch Med Sci 8(1):11 Ellenbogen KA, Wood MA, Shepard RK (2002) Delayed complications following pacemaker implantation. Pacing Clin Electrophysiol 25(8):1155–1158 Tsang TSM, Freeman WK, Barnes ME, Reeder GS, Packer DL, Seward JB (1998) Rescue echocardiographically guided pericardiocentesis for cardiac perforation complicating catheter-based procedures. J Am Coll Cardiol 32(5):1345–1350. 10.1016/s0735-1097(98)00390-8 Ho M-Y, Wang J-L, Lin Y-S, Mao C-T, Tsai M-L, Wen M-S et al (2014) Pericardiocentesis adverse event risk factors: A nationwide population-based Cohort Study. Cardiology 130(1):37–45. 10.1159/000368796 Akbarzadeh MA, Mollazadeh R, Sefidbakht S, Shahrzad S, Bahrololoumi Bafruee N (2017) Identification and management of right ventricular perforation using pacemaker and cardioverter-defibrillator leads: A case series and mini review. J Arrhythmia 33(1):1–5. 10.1016/j.joa.2016.05.005 Banaszewski M, Stępińska J (2012) Editorial right heart perforation by pacemaker leads. Archives Med Sci 1:11–13. 10.5114/aoms.2012.27273 Wu S-J, Fan Y-F, Chien C-Y (2021) Surgical strategies for cardiac perforation after catheter ablation or electrophysiology study. Int Heart J 62(6):1257–1264. 10.1536/ihj.21-201 Adar R (1987) The double iatrogenic hazard. JAMA: J Am Med Association 257(16):2164. 10.1001/jama.1987.03390160050012 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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1","display":"","copyAsset":false,"role":"figure","size":308188,"visible":true,"origin":"","legend":"\u003cp\u003eTOE showing the 1\u003csup\u003est\u003c/sup\u003e pericardial catheter within the RV.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8049595/v1/4f79b71bd4251a2cdd22e1ad.jpeg"},{"id":95504424,"identity":"abdd8b42-21fa-4c62-8168-ef8bcb87e8f2","added_by":"auto","created_at":"2025-11-10 05:44:44","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1186125,"visible":true,"origin":"","legend":"\u003cp\u003ePericardial catheter(left) and tip of temporary endocavitary pacemaker (TPM) lead (right) visualized.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8049595/v1/a8528deb2a745fc35b6d1766.jpeg"},{"id":95528442,"identity":"9b13eced-a62f-4d78-a427-66d08d687234","added_by":"auto","created_at":"2025-11-10 10:16:06","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1146764,"visible":true,"origin":"","legend":"\u003cp\u003eRemoval of pericardial catheter.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8049595/v1/c9e8b8dda6d7bf6035c5fc43.png"},{"id":95504433,"identity":"ddbb9216-5f7a-42e8-871b-3abeae25d525","added_by":"auto","created_at":"2025-11-10 05:44:45","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1032048,"visible":true,"origin":"","legend":"\u003cp\u003eHaemostasis with pledgeted Prolene 3/0 sutures.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8049595/v1/d9742a996ce6815e8d481d7a.png"},{"id":95531664,"identity":"25c01c23-bf8a-4e30-8799-0441a6fab08b","added_by":"auto","created_at":"2025-11-10 10:23:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5153729,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8049595/v1/099c8b03-1a4a-47eb-b78d-4e92754e41cb.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eDouble Whammy: A case report of two iatrogenic cardiac perforations in the same patient\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCardiac perforation is a rare but serious complication of pacemaker lead placement, with potentially fatal consequences if not recognized promptly. The reported incidence varies between 0.1–1% for permanent pacemaker implantation and can reach up to 10% for temporary pacing leads, particularly via femoral access due to limited control of lead direction.¹⁻³ While the complication is uncommon, its outcomes can be catastrophic, especially when associated with cardiac tamponade or hemodynamic collapse.\u003c/p\u003e\u003cp\u003eWe present a unique case of \u003cem\u003edouble iatrogenic right ventricular perforation\u003c/em\u003e in a patient who first sustained injury following temporary pacemaker (TPM) insertion and subsequently during echocardiography-guided pericardiocentesis. The case highlights diagnostic challenges, clinical decision-making in managing suspected lead perforation, and lessons for procedural safety.\u003c/p\u003e\n\u003ch3\u003eSummary figure\u003c/h3\u003e\n\u003cp\u003eTimeline of critical events.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003e-3 days\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOnset of dizziness and fatigue\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePresentation to hospital\u003c/p\u003e\u003cp\u003e- Diagnosis of complete heart block made via ECG\u003c/p\u003e\u003cp\u003e- ECHO showed mildly dilated LA \u0026amp; LV, with no other abnormality detected\u003c/p\u003e\u003cp\u003e- Admitted to CCU\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e+ 6 h\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDeveloped multiple episodes of short-run VF\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e+ 7 h\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTemporary endocavitary pacemaker (TPM) inserted via femoral approach\u003c/p\u003e\u003cp\u003ePost procedure ECHO showed TPM lead within RV and circumferential pericardial effusion 0.5-0.7cm\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e+ 7 h - +10 days\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAwaiting emergency funding approval for permanent pacemaker insertion.\u003c/p\u003e\u003cp\u003eMonitored in CCU, haemodynamically stable, daily ECGs and serial CXRs done\u003c/p\u003e\u003cp\u003eECHO repeated on Day 3 and 7 showing small stable pericardial effusion\u003c/p\u003e\u003cp\u003eIntermittent failure to capture pacing, lead repositioning on Day 4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e+ 10 days\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHaemodynamic collapse\u003c/p\u003e\u003cp\u003eBedside ECHO showed massive pericardial effusion (\u0026gt; 3cm) with RA \u0026amp; RV collapse indicating cardiac tamponade\u003c/p\u003e\u003cp\u003e1st attempt at rescue echo-guided pericardiocentesis\u003c/p\u003e\u003cp\u003e- Continuous drainage of blood from pericardial catheter\u003c/p\u003e\u003cp\u003e- Catheter spigoted\u003c/p\u003e\u003cp\u003e- Bubble study showed catheter within the RV\u003c/p\u003e\u003cp\u003e2nd attempt at rescue echo-guided pericardiocentesis successful, bubble study confirms catheter placement within pericardial space\u003c/p\u003e\u003cp\u003eUrgent surgical referral, taken to theatre\u003c/p\u003e\u003cp\u003e- Median sternotomy\u003c/p\u003e\u003cp\u003e- Intraoperative findings confirm 2 separate RV perforations\u003c/p\u003e\u003cp\u003e- Both repaired with pledgeted sutures\u003c/p\u003e\u003cp\u003e- Epicardial pacing leads placed\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e+ 10 days - +17 days\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePostoperatively haemodynamically stable on epicardial pacing\u003c/p\u003e\u003cp\u003eNo abnormalities detected on postoperative ECHO\u003c/p\u003e\u003cp\u003eSurgical drains removed\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e+ 17 days\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEpicardial leads removed and permanent pacemaker inserted\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e+ 19 days\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDischarge from hospital\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 61-year-old woman with a background of hypertension, dyslipidaemia, and type II diabetes mellitus presented to our centre with a three-day history of dizziness and fatigue consistent with symptomatic bradycardia. Physical examination was unremarkable. Electrocardiography confirmed complete heart block. Echocardiography revealed mild dilatation of the left atrium and ventricle, with no pericardial effusion. She was admitted to the coronary care unit (CCU) for monitoring.\u003c/p\u003e\u003cp\u003eFollowing several short runs of ventricular fibrillation, a temporary endocavitary pacemaker (TPM) was inserted via the right femoral vein. Initial pacing parameters included a capture threshold of 1.0 V at 0.5 ms, impedance of 600 Ω, and pacing rate of 80 bpm, achieving satisfactory capture and sensing. Post-procedure echocardiography demonstrated the TPM lead within the right ventricle and a small circumferential pericardial effusion (0.5–0.7 cm), which was managed conservatively.\u003c/p\u003e\u003cp\u003eThe patient remained in hospital while awaiting emergency funding approval for a permanent pacemaker. During this period, she was haemodynamically stable but had intermittent episodes of loss of capture, prompting one lead repositioning attempt on day 4, after which pacing parameters normalized. Daily ECGs were performed, and echocardiography was repeated on days 3 and 7, showing stable small effusion without chamber collapse. Serial chest X-rays confirmed appropriate lead position and no pneumothorax.\u003c/p\u003e\u003cp\u003eOn day 10 post-TPM insertion, she experienced sudden hemodynamic collapse. Bedside echocardiography revealed a massive pericardial effusion (\u0026gt; 3 cm) with right atrial and right ventricular collapse, consistent with cardiac tamponade. Emergency echocardiography-guided pericardiocentesis via subcostal approach yielded continuous drainage of blood. A bubble study confirmed the pericardial catheter tip within the right ventricle, indicating cardiac perforation. The catheter was spigoted, and a second attempt at pericardiocentesis successfully placed a catheter within the pericardial space, draining 400 mL of blood.\u003c/p\u003e\u003cp\u003eThe patient was urgently referred for surgical management. Intraoperative, transoesophageal echocardiography (TOE) in the operating theatre showed the pericardial catheter within the RV (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) with the TPM lead not visualised. A median sternotomy was performed to gain access to the heart. Operative findings revealed the tip of the pacing lead protruding out from the RV and the first pericardial catheter seen piercing the RV (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The second pericardial catheter was within the pericardial space. The pericardial catheters and the TPM lead were removed and the RV perforations were repaired with pledgeted Prolene 3/0 sutures (Figs.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e \u0026amp; 4). Standard epicardial pacing leads were placed prior to chest closure and the patient was admitted to the Cardiac Intensive Care Unit (CICU) postoperatively.\u003c/p\u003e\u003cp\u003eHer postoperative course was uneventful. Echocardiography showed no residual effusion, and pacing thresholds remained satisfactory. Epicardial leads were removed on day 7, and a permanent pacemaker was implanted the same day. She was discharged two days later in stable condition with no complications.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe rising number of cardiac interventions has naturally led to a proportional increase in iatrogenic cardiac injuries due to the growing procedural volume and complexity of patients undergoing such interventions.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Cardiac perforation during temporary pacemaker insertion occurs in up to \u003cb\u003e10%\u003c/b\u003e of cases and is more common when the femoral route is used, due to reduced control of lead trajectory and higher risk of wall penetration.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003ePericardiocentesis, although lifesaving, carries a small but definite risk of myocardial puncture, particularly in emergent or technically challenging settings, with reported incidences of \u003cb\u003e\u0026lt;\u0026thinsp;1%\u003c/b\u003e.\u003csup\u003e8\u003c/sup\u003e This case is remarkable in that both complications, TPM-related perforation and pericardiocentesis-induced perforation, occurred sequentially in the same patient.\u003c/p\u003e\u003cp\u003eFailure to capture and new or enlarging pericardial effusion following TPM placement are early indicators of lead perforation.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e In this patient, intermittent capture failure and persistent small effusion might have signalled an evolving perforation. Regular echocardiography and vigilant clinical correlation are essential, as even mild effusions can progress rapidly to tamponade. Early involvement of cardiothoracic surgery is advised when there is evidence of lead perforation or haemodynamic instability. Surgical exploration via median sternotomy and open repair is warranted in cases of persistent haemorrhage with haemodynamic instability, rapid progression of pericardial effusion, or if closed pericardiocentesis fails.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Perforations may be repaired with sutures, patch-and-glue, or a combination of the two with or without the use of extracorporeal circulation and cardioplegic arrest.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCardiac perforation is a rare but life-threatening complication of both pacemaker implantation and pericardiocentesis. For this devastating complication to occur twice in the same patient is both remarkable and instructive. This case underscores the importance of early recognition of lead perforation and careful management of iatrogenic cardiac injuries. When faced with unexplained pericardial effusion or pacing abnormalities, clinicians should maintain a high index of suspicion and escalate promptly for echocardiographic evaluation and surgical consultation.\u003c/p\u003e\u003cp\u003ePrevious studies have shown that when a patient sustains an iatrogenic injury, they are statistically more likely to experience another.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Whether this arises from suboptimal operator performance, overzealous attempts to rectify the initial problem, or simply the inherent risks of medical intervention, the lesson remains clear: vigilance and humility are essential in the pursuit of patient safety.\u003c/p\u003e\u003cp\u003eMedicine is, after all, a human endeavour and to err is human. If we are to prevent such injuries, they must be studied and reported openly, not to assign blame, but to foster learning and improvement. Eliminating iatrogenic harm requires both technical precision and a culture of transparency that allows practitioners to examine mistakes without fear, ensuring that every complication serves as a catalyst for safer care.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eNone to declare\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eNone\u003c/p\u003e\n\u003ch3\u003eStatement of consent\u003c/h3\u003e\n\u003cp\u003e The authors confirm that written informed consent for submission and publication of this case report, including images and associated text, has been obtained in-line with COPE guidelines.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMahapatra S, Bybee KA, Bunch TJ, Espinosa RE, Sinak LJ, McGoon MD et al (2005) Incidence and predictors of cardiac perforation after permanent pacemaker placement. Heart Rhythm 2(9):907\u0026ndash;911\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLaborderie J, Barandon L, Ploux S, Deplagne A, Mokrani B, Reuter S et al (2008) Management of subacute and delayed right ventricular perforation with a pacing or an implantable cardioverter-defibrillator lead. Am J Cardiol 102(10):1352\u0026ndash;1355\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTimperley J, Leeson P, Mitchell AR, Betts T (eds) (2018) Oxford Specialist Handbook of Pacemakers and ICDs, 2nd edn. Oxford University Press\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKumar R (2017) Management of Accidental and Iatrogenic Foreign Body Injuries to Heart- Case Series. Journal of Clinical and Diagnostic Research\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBanaszewski M, Stępińska J (2012) Right heart perforation by pacemaker leads. Arch Med Sci 8(1):11\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEllenbogen KA, Wood MA, Shepard RK (2002) Delayed complications following pacemaker implantation. Pacing Clin Electrophysiol 25(8):1155\u0026ndash;1158\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTsang TSM, Freeman WK, Barnes ME, Reeder GS, Packer DL, Seward JB (1998) Rescue echocardiographically guided pericardiocentesis for cardiac perforation complicating catheter-based procedures. 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Cardiology 130(1):37\u0026ndash;45. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1159/000368796\u003c/span\u003e\u003cspan address=\"10.1159/000368796\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAkbarzadeh MA, Mollazadeh R, Sefidbakht S, Shahrzad S, Bahrololoumi Bafruee N (2017) Identification and management of right ventricular perforation using pacemaker and cardioverter-defibrillator leads: A case series and mini review. J Arrhythmia 33(1):1\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.joa.2016.05.005\u003c/span\u003e\u003cspan address=\"10.1016/j.joa.2016.05.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBanaszewski M, Stępińska J (2012) Editorial right heart perforation by pacemaker leads. Archives Med Sci 1:11\u0026ndash;13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5114/aoms.2012.27273\u003c/span\u003e\u003cspan address=\"10.5114/aoms.2012.27273\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWu S-J, Fan Y-F, Chien C-Y (2021) Surgical strategies for cardiac perforation after catheter ablation or electrophysiology study. Int Heart J 62(6):1257\u0026ndash;1264. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1536/ihj.21-201\u003c/span\u003e\u003cspan address=\"10.1536/ihj.21-201\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAdar R (1987) The double iatrogenic hazard. JAMA: J Am Med Association 257(16):2164. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jama.1987.03390160050012\u003c/span\u003e\u003cspan address=\"10.1001/jama.1987.03390160050012\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Queen Elizabeth II Hospital","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"cardiac perforation, iatrogenic, interventional cardiology, cardiothoracic surgery, pacemaker, pericardiocentesis","lastPublishedDoi":"10.21203/rs.3.rs-8049595/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8049595/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eCardiac perforation is an uncommon but potentially fatal complication of pacemaker lead placement and pericardiocentesis. We report the case of a 61-year-old woman who sustained two distinct iatrogenic right ventricular perforations, the first following temporary endocavitary pacemaker (TPM) insertion and the second during rescue echocardiography-guided pericardiocentesis performed for cardiac tamponade after initially presented with symptomatic bradycardia secondary to complete heart block. Emergency surgery via median sternotomy revealed both perforations, which were repaired with pledgeted sutures. Her postoperative recovery was uneventful, and a permanent pacemaker was implanted prior to discharge. This case highlights the rare occurrence of sequential iatrogenic cardiac perforations in a single patient and underscores the importance of vigilance, timely recognition of pacing complications, and multidisciplinary management to prevent fatal outcomes.\u003c/p\u003e","manuscriptTitle":"Double Whammy: A case report of two iatrogenic cardiac perforations in the same patient","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-10 05:44:39","doi":"10.21203/rs.3.rs-8049595/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e360b8c3-bdf9-4101-a548-8395715a4fa2","owner":[],"postedDate":"November 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":57564739,"name":"Cardiothoracic Surgery"},{"id":57564740,"name":"Cardiac \u0026 Cardiovascular Systems"}],"tags":[],"updatedAt":"2025-11-10T05:44:39+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-10 05:44:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8049595","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8049595","identity":"rs-8049595","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}