Leadless pacemaker implantation after delayed atrial lead perforation and pacemaker energy exhaustion: A case report

Leadless pacemaker implantation after delayed atrial lead perforation and pacemaker energy exhaustion: A case report | 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 Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Leadless pacemaker implantation after delayed atrial lead perforation and pacemaker energy exhaustion: A case report Yichang Zhao, Liping Su, Yuchen Gao, Hao Wang, Chao Luan, Jinqiu Liu, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5171162/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 27 Dec, 2024 Read the published version in BMC Cardiovascular Disorders → Version 1 posted 15 You are reading this latest preprint version Abstract Background Delayed lead perforation is a rare complication of a cardiac implantable electronic device (CIED). Clinical presentations range from completely asymptomatic to pericardial tamponade. Surgical lead extraction is recommended and percutaneous lead extraction with surgical backup is an alternative method. Case presentation A male with a history of paroxysmal atrial fibrillation and sick sinus syndrome implanted a dual-chamber pacemaker with two passive fixation lead. He was on oral anticoagulants and played golf for almost 1 hour every day after implantation. However, he complained of thoracic stabbing in the sternal manubrium with abnormal findings on pacemaker interrogation. Imaging confirmed the perforated atrial electrode with lead tip protrusion from the pericardium adjacent to the inferior wall of the main right pulmonary artery, but with no pericardial effusion. A lead removal by transvenous approach with surgical support was suggested, but the patient refused. Given the stable condition of the patient, conservative treatment was chosen in the absence of complications during a follow-up period of 14 years. Then pacemaker energy was exhausted with a ventricular lead threshold increased. A leadless pacemaker was implanted. Conclusions Chest pain in CIED with abnormal electrical parameters, especially ongoing treatment with anticoagulants and regular physical activity, should always raise suspicion of lead perforation. A conservative strategy may be appropriate and feasible for those in the absence of perforation-related complications. For patients with pacemaker energy exhaustion combined with ventricular lead aging after conservative treatment of lead perforation, leadless pacemaker may be an alternative approach. lead perforation leadless pacemaker conservative approach energy exhaustion case report Figures Figure 1 Figure 2 Figure 3 Background Lead perforation is a rare complication of a cardiac implantable electronic device (CIED) with a median prevalence of 0.4% ( 1 ), which is more often affected by the right ventricular lead than the atrial lead ( 2 ). Delayed lead perforation, defined as longer than 30 days, is highly variable in presentation, ranging from completely asymptomatic to pericardial tamponade ( 3 ). Management of lead perforation includes conservative or lead extraction based on the symptoms and life-threatening complications. Surgical lead extraction is recommended by expert consensus ( 4 ), and percutaneous lead extraction with surgical backup is an alternative method ( 5 , 6 ). Here we report on a male patient with atrial lead perforation that occurred 10 months after a dual-chamber implantation without severe complications. After battery energy exhaustion, he preferred conservative treatment and had a leadless pacemaker implanted, with the entire time span being 16 years. Case presentation A 59-year-old man with paroxysmal atrial fibrillation (PaAF) presented with palpitations and underwent radiofrequency catheter ablation on Aug. 23, 2001. He was readmitted to the hospital, presented with dizziness, syncope, and intermittent palpitations, and was diagnosed with sick sinus syndrome and PaAF on Oct. 21, 2007. Several episodes of syncope were observed during hospitalization, while electrocardiogram (ECG) monitoring showed sinus pauses (6.08 s). A temporary pacemaker was implanted in the right ventricular apex on the second day. Owing to PaAF, the patient was on oral anticoagulants (warfarin 3.125 mg once/day), which had been stopped 24 hours before implantation. A dual-chamber pacemaker (a tined J-shaped atrial lead, St. Jude Medical, 1642T/52 cm; a tined ventricular lead, St. Jude Medical, 1646T/58 cm; generator, Verity ADx XL DR 5356; St. Jude Medical, Sylmar, America) was implanted in Oct. 30, 2007. The atrial lead was fixed passively in the anterolateral right atrial appendage (RAA), and the ventricular lead was fixed in the apical right ventricle (RV) (Fig. 1 A, Jan. 2, 2008). The pacemaker was assigned to pacing programmed to a base rate of 60 bpm and rate-adaptive pacing (DDDR-60), with both lead parameters within the normal range (Fig. 2 A). Six months after implantation, the patient played golf for almost 1 hour every day and swam occasionally. However, he suddenly complained of thoracic stabbing in the sternal manubrium. The pacemaker measurements showed significant worsening of lead impedance of more than 2,500 Ω (Fig. 2 A) on Aug. 8, 2008, which was 10 months after implantation and 4 months after golf. Atrial pacing failure was also observed occasionally. Chest x-rays (CXR) indicated no obvious lead perforation or fracture (Fig. 1 B). Then, atrial impedance gradually decreased to 780 Ω, but the atrial lead threshold increased to 4.5 V at 0.4 ms (Fig. 2 A). Pericardial effusion was absent on the cardiac ultrasound. In consideration of CXR excluding lead perforation and fracture, device interrogation excluding energy exhaustion, and impedance reducing to the normal range, the elevated threshold might be associated with atrial fibrosis at the implant site because of the patient’s PaAF history. The pacemaker was programmed to a base rate of 45 bpm to reduce energy waste. The patient responded well to analgesic therapy. Relieved symptoms and normal pacing resulted in patient discharge. During the follow-up from Sep. to Dec. 2008, the atrial lead threshold fluctuated between 2.75 V/0.4 ms and 3.75 V/0.4 ms (Fig. 2 A), and percent atrial pacing between 7% and 22% (Fig. 2 B). However, the patient complained of recurrent chest pain on Jan. 6, 2009. Pericardial effusion was still absent on cardiac ultrasound, and the atrial lead threshold was still 3.75 V/0.4 ms. Owing to the long-term golf and symptom characteristics, a lead perforation was suspected. Three-dimensional (3D) reconstruction of coronary computed tomography angiography (CCTA) confirmed the perforated atrial electrode with lead tip protrusion from the pericardium adjacent to the inferior wall of the main right pulmonary artery (MRPA), but with no pericardial effusion and no contrast extravasation seen (Fig. 1 C– 1 F). He was hemodynamically stable, and chest pain was alleviated when the pacing mode changed to VVI with a base rate of 45 bpm. A lead removal by transvenous approach with surgical support was suggested, but the patient refused. In view of the patient’s stable clinical status and the absence of any mechanical complications, we advised vigilant and close follow-up for anything. The patient was discharged with a plan for interval transthoracic echocardiography (TEE) to monitor pericardial effusion. During his follow-up, PaAF became more frequent and evolved into persistent AF in April 2013. CCTA was repeated in Aug. 2013 and Aug. 2023, respectively, and there was no migration in the position of the lead tip. He underwent regular clinical follow-ups and device interrogations. Device interrogation found pacemaker energy exhaustion on Aug. 15, 2023 with a ventricular lead threshold increase of 2.75 V/0.8 ms. In consideration of the aging of the ventricular lead, which had been used for 16 years, the low ventricular pacing burden (12–16%), and the patient’s preferences, a leadless pacemaker (MC1AVR1, Medtronic, America) was implanted at the right ventricular septum on Sep. 14, 2023 (Figs. 1 G and 1 H). The pacing mode was programmed to a base rate of 50 bpm and VVI with a ventricular threshold of 0.25 V/ 0.24 ms, sensitivity of 11.3 mV, and impedance of 740 Ω. One month after the procedure, it showed a threshold of 0.13 V/ 0.24 ms, impedance of 830 Ω, and pacing burden of 11%. The patient was doing very well 3 months after the last hospital discharge. Figure 3 shows a timeline of the case. Discussion and Conclusions To the best of our knowledge, this is the first report of a very late occurrence of a passive atrial lead perforation managed by a conservative approach and followed up for 16 years with no complications. A leadless pacemaker was implanted after battery energy exhaustion and ventricular lead aging. Delayed lead perforation defined 30 days or more after implantation is a rare complication. It is highly variable in presentation, ranging from completely asymptomatic to frank tamponade ( 3 ). Chest pain was the most frequent symptom for delayed perforation, which was typically pleuritic, localized, sharp, or electrical, sometimes with a pulsatile component, including positional or respiratory variability ( 7 ). Apart from suggestive clinical symptoms, significant lead parameter changes during pacemaker interrogation associated with definite lead perforation ( 5 , 8 , 9 ). The patient complained of chest pain, and abnormal electrical parameters should be treated with a high index of suspicion for perforation. However, transthoracic echocardiography (TTE) and CXR showed no abnormalities related to the pacemaker or pericardial effusion. Temporary improvement in symptoms and electrical parameters led to the ignorance of perforation. Therefore, further examinations, such as CT, were not performed on the patient. Recent studies have established CT as the modality of choice for diagnosing cardiac lead perforations with good inter-observer agreement ( 5 , 10 ) of 97% sensitivity ( 7 ). A retrospective study showed the accuracies of CXR, TTE, and electrocardiography–gated contrast-enhanced cardiac CT imaging for the diagnosis of cardiac lead perforation were 73.1%, 82.7%, and 98.1%, respectively ( 10 ). In this case, CT is useful for documenting lead position and assessing lead perforation, whereas the artifacts at the tip of the lesion could make assessment of surrounding tissues difficult. However, cardiac contrast CT provided 3D images near the lead tip and clearly showed the lead tip protrusion from the pericardium adjacent to the inferior wall of the MRPA in the absence of vascular injury, a tamponade, or hemothorax. Therefore, cardiac contrast CT is considered to be more accurate than CT in confirming lead perforation. The patient had three major risk factors for lead perforation: a history of temporary pacing, anticoagulant use, and regular physical activity, but other risk factors (active fixation lead, female sex, older age, steroid therapy, body mass index of < 20 kg/m 2 , lead long procedure times, and infections) were absent ( 11 , 12 ). The main reason for perforation may be repeated golf swing, because the lead perforated four months after repeated identical swing action. The understanding of the specific mechanism of perforation remains subject to speculation. The action resulted in the electrode being pulled repeatedly, increasing tension, which might have created a strong force per unit area ( 13 ) toward the atrial wall, leading to the lead perforation. The mechanism responsible for delayed lead perforation has been proposed as a gradual process in which the combination of contracting myocardium, reactive fibrosis, and the lead itself are thought to “self-seal” the heart and the investing visceral pericardium, thereby limiting rapid fluid accumulation and the size of the resulting effusion ( 3 , 11 ). Our patient had markedly high impedance, an increase in capture threshold, and then impedance decreased to normal, with a higher threshold value compared to the early postoperative threshold. Impedance may vary depending on the tissue components around the lead tip, such as muscle, blood (decreased), and air (e.g., lung, pericardial space, and increased) ( 14 ). The atrial lead tip gradually protruded from the RAA to near the inferior wall of the MRPA and still in the pericardium, and did not penetrate the artery. The tip was then adhered to thrombo-fibrotic lead encapsulations ( 15 ) and surrounding myocardium or tissues. Therefore, the process of perforation corresponded to changes in electrical parameters. The management of lead perforation includes conservative, surgical, and transvenous lead extraction, depending on the patient’s symptoms, hemodynamic status, and presence of any significant pericardial or pleural effusion, although lead extraction is usually mandated ( 16 , 17 ). Surgical removal is usually considered the preferred strategy ( 11 ), but removal by traction under fluoroscopic guidance has also shown to be safe and effective ( 6 , 9 ). However, a lack of conservative management in part relates to the criteria used for case identification and the definitions chosen for clinically significant cardiac perforation ( 7 ). Cases where a conservative strategy may be appropriate include those in the absence of perforation-related pain, bleeding, or malfunction, or in which perforation-related symptoms have resolved without significant pericardial effusion, or in which perforations were detected incidentally by CT ( 7 , 17 ). In most instances, it has been suggested that conservative treatment without removal of the right atrial lead is a viable option for treatment, especially for microdislodgement. When planning a conservative strategy, the patient’s wishes must be considered through an open discussion regarding the potential future risk of complications requiring re-intervention versus the upfront risks of lead revision ( 7 ). Some studies have reported that anticoagulation status was associated with pericardial tamponade ( 7 , 18 ). Although anticoagulant use of the patient, the lead tip did not penetrate into the artery in the absence of tamponade. Regarding the patient’s preference, chest pain diminished after the mode changed, ventricular pacing parameters were stable, and a conservative approach was finally administered. During a follow-up period of nearly 16 years after implantation, perforation-related symptoms or pericardial effusion were always absent in the patient, in addition to a higher threshold of atrial lead. When pacemaker interrogation monitored energy exhaustion and increased threshold of aging ventricular lead, management options in this patient included placement of new leads in the same pocket with a new pulse generator or leadless pacemaker. The criteria used for case selection remain unclear and are not clearly defined. Considering atrial perforation, energy exhaustion, and two abandoned leads, a leadless pacemaker was eventually implanted, which is the first reported case. Herein, we describe the first case of leadless pacemaker implantation after delayed atrial lead perforation and pacemaker energy exhaustion. In view of lead perforation, conservative treatment was chosen in the absence of complications during a follow-up period of 16 years. A conservative strategy may be appropriate and feasible for those in the absence of perforation-related complications. For patients with pacemaker energy exhaustion combined with ventricular lead aging after conservative treatment of lead perforation, leadless pacemaker may be an alternative approach. Declarations Corresponding authors: Jinqiu Liu and Feifei Chen. Ethics approval and consent to participate Not applicable. Consent for publication Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal. Data availability All available information is contained within the present manuscript. Competing interests The authors declare that they have no competing interests. Fundings This work was supported by the National Natural Science Foundation of China (81700301), Scientific Research Foundation of Education Department of Liaoning Province (LZ2020058), Liaoning Revitalization Talents Program (XLYC2203195) and Scientific Research Project of Dalian Medical Key Specialty “Climbing Peak Plan” (2022DF016). Authors’ contributions Liu JQ and Chen FF interpreted the patient data and wrote the manscript. Zhao YC and Su LP collected and analyzed the clinic data. Wang H performed the imaging examination. Gao YC collated the pacemaker data and Luan C draw Figure 2. All authors read and approved the final manuscript. Acknowledgments Not applicable. Clinical trial number Not applicable. References Vamos M, Erath JW, Benz AP, et al. Incidence of cardiac perforation with conventional and with leadless pacemaker systems: a systematic review and meta-analysis. J Cardiovasc Electrophysiol 2017;28:336-346. CanoO, AndrésA, Alonso P, 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. Issa ZF, Issa TZ. Feasibility and safety of percutaneous lead revision for subacute and delayed cardiac device lead perforation. JACC Clin Electrophysiol 2021;7:26-35. Wilkoff BL, Love CJ, Byrd CL, et al. Transvenous lead extraction: Heart Rhythm Society expert consensus on facilities, training, indications, and patient management: this document was endorsed by the American Heart Association (AHA). Heart Rhythm 2009;6:1085-1104. Rajkumar CA, Claridge S, Jackson T, et al. Diagnosis and management of iatrogenic cardiac perforation caused by pacemaker and defibrillator leads. Europace 2017;19:1031-1037. Zhou X, Ze F, Li D, et al. Outcomes of transvenous lead extraction in patients with lead perforation: A single-center experience. Clin Cardiol 2020;43:386-393. Waddingham PH, Elliott J, Bates A, et al. Iatrogenic cardiac perforation due to pacemaker and defibrillator leads: a contemporary multicentre experience. Europace 2022;24:1824-1833. Acha MR, Rafael A, Keaney JJ, et al. The management of cardiac implantable electronic device lead perforations: a multicentre study. Europace 2019;21: 937-943. Laborderie J, Barandon L, Ploux S, et al. Management of subacute and delayed right ventricular perforation with a pacing or an implantable cardioverter-defibrillator lead. Am J Cardiol 2008;102: 1352-1355. Zhang X, Zheng C, Wang P, et al. Assessment of cardiac lead perforation: comparison among chest radiography, transthoracic echocardiography and electrocardiography-gated contrast- enhanced cardiac CT. Eur Radiol 2019;29:963-974. Akbarzadeh MA, Mollazadeh R, Sefidbakht S, et al. Identification and management of right ventricular perforation using pacemaker and cardioverter- defibrillator leads: a case series and mini review. J. Arrhythmia 2017;33:1-5. Haque MA, Roy S, Biswas B. Perforation by permanent pacemaker lead: how late can they occur? Cardiol J 2012;19:326-327. Khan MN, Joseph G, Khaykin Y, et al. Delayed lead perforation: a disturbing trend. Pacing Clin Electrophysiol 2005;28:251-253. Ahmed A, Shokr M, Lieberman R. Subacute right ventricular perforation by pacemaker lead causing left-sided hemothorax and epicardial hematoma. Case Rep Cardiol 2017;1264734. Keiler J, Schulze M, Dreger R, et al. Quantitative and qualitative assessment of adhesive thrombo-fibrotic lead encapsulations (TFLE) of pacemaker and ICD leads in arrhythmia patients-A post mortem study. Front Cardiovasc Med 2020;7:602179. Sanoussi A, El Nakadi B, Lardinois I, et al. Late right ventricular perforation after permanent pacemaker implantation: how far can the lead go? Pacing Clin Electrophysiol 2005;28:723-725. Kusumoto FM, Schoenfeld MH, Wilkoff BL, et al. HRS expert consensus statement on cardiovascular implantable electronic device lead management and extraction. Heart Rhythm 2017;14:e503-e551. Mahapatra Srijoy, Bybee Kevin A, Jared Bunch T, et al. Incidence and predictors of cardiac perforation after permanent pacemaker placement. Heart Rhythm 2005;2:907e11. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 27 Dec, 2024 Read the published version in BMC Cardiovascular Disorders → Version 1 posted Editorial decision: Revision requested 06 Dec, 2024 Reviewers agreed at journal 03 Dec, 2024 Reviews received at journal 01 Dec, 2024 Reviews received at journal 28 Nov, 2024 Reviewers agreed at journal 28 Nov, 2024 Reviewers agreed at journal 23 Nov, 2024 Reviews received at journal 02 Nov, 2024 Reviewers agreed at journal 26 Oct, 2024 Reviewers agreed at journal 25 Oct, 2024 Reviewers agreed at journal 24 Oct, 2024 Reviewers invited by journal 23 Oct, 2024 Editor invited by journal 10 Oct, 2024 Editor assigned by journal 08 Oct, 2024 Submission checks completed at journal 08 Oct, 2024 First submitted to journal 28 Sep, 2024 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 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-5171162","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":387123103,"identity":"eddba0f5-e357-423b-83d5-a097892b3d75","order_by":0,"name":"Yichang Zhao","email":"","orcid":"","institution":"First Affiliated Hospital of Dalian Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yichang","middleName":"","lastName":"Zhao","suffix":""},{"id":387123104,"identity":"a298020f-b3a1-4cea-9351-71f80cf85469","order_by":1,"name":"Liping Su","email":"","orcid":"","institution":"First Affiliated Hospital of Dalian Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Liping","middleName":"","lastName":"Su","suffix":""},{"id":387123105,"identity":"53ef5973-b675-4090-b15e-e74617cffb73","order_by":2,"name":"Yuchen Gao","email":"","orcid":"","institution":"First Affiliated Hospital of Dalian Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yuchen","middleName":"","lastName":"Gao","suffix":""},{"id":387123106,"identity":"a65b5383-db2e-499c-b858-197701d756c6","order_by":3,"name":"Hao Wang","email":"","orcid":"","institution":"First Affiliated Hospital of Dalian Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hao","middleName":"","lastName":"Wang","suffix":""},{"id":387123107,"identity":"2ca9fe4f-bb0c-42a4-a60a-49d4e2ddcc2f","order_by":4,"name":"Chao Luan","email":"","orcid":"","institution":"First Affiliated Hospital of Dalian Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Chao","middleName":"","lastName":"Luan","suffix":""},{"id":387123108,"identity":"b1c065e1-a9f2-441d-96ce-2694217689e0","order_by":5,"name":"Jinqiu Liu","email":"","orcid":"","institution":"First Affiliated Hospital of Dalian Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jinqiu","middleName":"","lastName":"Liu","suffix":""},{"id":387123109,"identity":"2fe0e34f-1b33-41d1-be0a-0aa71642686c","order_by":6,"name":"Feifei Chen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA30lEQVRIiWNgGAWjYFCCBAYGxgYGBvYGxsYHCRU2JGjhOcDYbPDgTBpJWhjYJB+2HSKsQb49+eGNnzts8njYm9sqEtgOMPC3dyfg1WJw5pmxZe+ZtGIenoNtNxJ47jBInDm7Ab8WiQQzaca2w4n7JRKBWiSeAUVy8WuRn5H+Dajlf2KP/MO2ggSDw4S1MNzIAdlyILFHgrGNISGBCC0GZ94UW/a2JSf28CQ2SyQcSOMh6Bf59vSNN3622SX2sB9/+PHnPxs5/vZeAg4DAglkDg9B5RhaRsEoGAWjYBRgAAClZk7O2ZzuLQAAAABJRU5ErkJggg==","orcid":"","institution":"First Affiliated Hospital of Dalian Medical University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Feifei","middleName":"","lastName":"Chen","suffix":""}],"badges":[],"createdAt":"2024-09-28 15:23:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5171162/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5171162/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12872-024-04448-z","type":"published","date":"2024-12-27T15:56:50+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":71560813,"identity":"524a0922-a5d9-4d43-b3cd-99421a196266","added_by":"auto","created_at":"2024-12-16 16:54:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":741729,"visible":true,"origin":"","legend":"\u003cp\u003eImaging changes showing atrial lead perforation. A and B: Chest x-ray 6 days and 10 months after the implant, showing no displacement of the leads. C–F: Coronary computed tomography angiography showed atrial lead perforation; the broken circles indicate the lead tip protruding from the pericardium adjacent to the inferior wall of the main right pulmonary artery (pentagrams). G and H: Fluoroscopic images of the lead and leadless pacemaker.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-5171162/v1/c86840e1d948435739c8da59.png"},{"id":71559668,"identity":"ed3a77a8-72cc-4b2a-ac87-aac844148602","added_by":"auto","created_at":"2024-12-16 16:46:52","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":183264,"visible":true,"origin":"","legend":"\u003cp\u003eTemporal changes in lead parameters. A: Atrial and ventricular lead threshold, atrial lead impedance, and pulse width. B: Pacing ratio.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-5171162/v1/920fab8599b2247d9910e0ab.png"},{"id":71559669,"identity":"95c86091-7128-48b8-9273-58edb3d17ef0","added_by":"auto","created_at":"2024-12-16 16:46:52","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":173610,"visible":true,"origin":"","legend":"\u003cp\u003eTimeline of the case.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-5171162/v1/5ab5e34ab01d97fb7cc4ab75.png"},{"id":72640241,"identity":"499b64e9-d31a-4f35-a335-6a1a0d809bec","added_by":"auto","created_at":"2024-12-30 16:02:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1465263,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5171162/v1/975cca49-65c1-4dc3-b49b-efb6953bb35f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Leadless pacemaker implantation after delayed atrial lead perforation and pacemaker energy exhaustion: A case report","fulltext":[{"header":"Background","content":"\u003cp\u003eLead perforation is a rare complication of a cardiac implantable electronic device (CIED) with a median prevalence of 0.4% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), which is more often affected by the right ventricular lead than the atrial lead (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Delayed lead perforation, defined as longer than 30 days, is highly variable in presentation, ranging from completely asymptomatic to pericardial tamponade (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Management of lead perforation includes conservative or lead extraction based on the symptoms and life-threatening complications. Surgical lead extraction is recommended by expert consensus (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), and percutaneous lead extraction with surgical backup is an alternative method (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Here we report on a male patient with atrial lead perforation that occurred 10 months after a dual-chamber implantation without severe complications. After battery energy exhaustion, he preferred conservative treatment and had a leadless pacemaker implanted, with the entire time span being 16 years.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 59-year-old man with paroxysmal atrial fibrillation (PaAF) presented with palpitations and underwent radiofrequency catheter ablation on Aug. 23, 2001. He was readmitted to the hospital, presented with dizziness, syncope, and intermittent palpitations, and was diagnosed with sick sinus syndrome and PaAF on Oct. 21, 2007. Several episodes of syncope were observed during hospitalization, while electrocardiogram (ECG) monitoring showed sinus pauses (6.08 s). A temporary pacemaker was implanted in the right ventricular apex on the second day. Owing to PaAF, the patient was on oral anticoagulants (warfarin 3.125 mg once/day), which had been stopped 24 hours before implantation. A dual-chamber pacemaker (a tined J-shaped atrial lead, St. Jude Medical, 1642T/52 cm; a tined ventricular lead, St. Jude Medical, 1646T/58 cm; generator, Verity ADx XL DR 5356; St. Jude Medical, Sylmar, America) was implanted in Oct. 30, 2007. The atrial lead was fixed passively in the anterolateral right atrial appendage (RAA), and the ventricular lead was fixed in the apical right ventricle (RV) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA, Jan. 2, 2008). The pacemaker was assigned to pacing programmed to a base rate of 60 bpm and rate-adaptive pacing (DDDR-60), with both lead parameters within the normal range (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSix months after implantation, the patient played golf for almost 1 hour every day and swam occasionally. However, he suddenly complained of thoracic stabbing in the sternal manubrium. The pacemaker measurements showed significant worsening of lead impedance of more than 2,500 Ω (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA) on Aug. 8, 2008, which was 10 months after implantation and 4 months after golf. Atrial pacing failure was also observed occasionally. Chest x-rays (CXR) indicated no obvious lead perforation or fracture (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). Then, atrial impedance gradually decreased to 780 Ω, but the atrial lead threshold increased to 4.5 V at 0.4 ms (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). Pericardial effusion was absent on the cardiac ultrasound. In consideration of CXR excluding lead perforation and fracture, device interrogation excluding energy exhaustion, and impedance reducing to the normal range, the elevated threshold might be associated with atrial fibrosis at the implant site because of the patient’s PaAF history. The pacemaker was programmed to a base rate of 45 bpm to reduce energy waste. The patient responded well to analgesic therapy. Relieved symptoms and normal pacing resulted in patient discharge. During the follow-up from Sep. to Dec. 2008, the atrial lead threshold fluctuated between 2.75 V/0.4 ms and 3.75 V/0.4 ms (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA), and percent atrial pacing between 7% and 22% (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB).\u003c/p\u003e \u003cp\u003eHowever, the patient complained of recurrent chest pain on Jan. 6, 2009. Pericardial effusion was still absent on cardiac ultrasound, and the atrial lead threshold was still 3.75 V/0.4 ms. Owing to the long-term golf and symptom characteristics, a lead perforation was suspected. Three-dimensional (3D) reconstruction of coronary computed tomography angiography (CCTA) confirmed the perforated atrial electrode with lead tip protrusion from the pericardium adjacent to the inferior wall of the main right pulmonary artery (MRPA), but with no pericardial effusion and no contrast extravasation seen (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC–\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eF). He was hemodynamically stable, and chest pain was alleviated when the pacing mode changed to VVI with a base rate of 45 bpm. A lead removal by transvenous approach with surgical support was suggested, but the patient refused. In view of the patient’s stable clinical status and the absence of any mechanical complications, we advised vigilant and close follow-up for anything. The patient was discharged with a plan for interval transthoracic echocardiography (TEE) to monitor pericardial effusion. During his follow-up, PaAF became more frequent and evolved into persistent AF in April 2013. CCTA was repeated in Aug. 2013 and Aug. 2023, respectively, and there was no migration in the position of the lead tip. He underwent regular clinical follow-ups and device interrogations.\u003c/p\u003e \u003cp\u003eDevice interrogation found pacemaker energy exhaustion on Aug. 15, 2023 with a ventricular lead threshold increase of 2.75 V/0.8 ms. In consideration of the aging of the ventricular lead, which had been used for 16 years, the low ventricular pacing burden (12–16%), and the patient’s preferences, a leadless pacemaker (MC1AVR1, Medtronic, America) was implanted at the right ventricular septum on Sep. 14, 2023 (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eG and \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eH). The pacing mode was programmed to a base rate of 50 bpm and VVI with a ventricular threshold of 0.25 V/ 0.24 ms, sensitivity of 11.3 mV, and impedance of 740 Ω. One month after the procedure, it showed a threshold of 0.13 V/ 0.24 ms, impedance of 830 Ω, and pacing burden of 11%. The patient was doing very well 3 months after the last hospital discharge. Figure\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows a timeline of the case.\u003c/p\u003e "},{"header":"Discussion and Conclusions","content":"\u003cp\u003eTo the best of our knowledge, this is the first report of a very late occurrence of a passive atrial lead perforation managed by a conservative approach and followed up for 16 years with no complications. A leadless pacemaker was implanted after battery energy exhaustion and ventricular lead aging.\u003c/p\u003e\u003cp\u003eDelayed lead perforation defined 30 days or more after implantation is a rare complication. It is highly variable in presentation, ranging from completely asymptomatic to frank tamponade (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Chest pain was the most frequent symptom for delayed perforation, which was typically pleuritic, localized, sharp, or electrical, sometimes with a pulsatile component, including positional or respiratory variability (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Apart from suggestive clinical symptoms, significant lead parameter changes during pacemaker interrogation associated with definite lead perforation (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The patient complained of chest pain, and abnormal electrical parameters should be treated with a high index of suspicion for perforation. However, transthoracic echocardiography (TTE) and CXR showed no abnormalities related to the pacemaker or pericardial effusion. Temporary improvement in symptoms and electrical parameters led to the ignorance of perforation. Therefore, further examinations, such as CT, were not performed on the patient.\u003c/p\u003e\u003cp\u003eRecent studies have established CT as the modality of choice for diagnosing cardiac lead perforations with good inter-observer agreement (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) of 97% sensitivity (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). A retrospective study showed the accuracies of CXR, TTE, and electrocardiography–gated contrast-enhanced cardiac CT imaging for the diagnosis of cardiac lead perforation were 73.1%, 82.7%, and 98.1%, respectively (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). In this case, CT is useful for documenting lead position and assessing lead perforation, whereas the artifacts at the tip of the lesion could make assessment of surrounding tissues difficult. However, cardiac contrast CT provided 3D images near the lead tip and clearly showed the lead tip protrusion from the pericardium adjacent to the inferior wall of the MRPA in the absence of vascular injury, a tamponade, or hemothorax. Therefore, cardiac contrast CT is considered to be more accurate than CT in confirming lead perforation.\u003c/p\u003e\u003cp\u003eThe patient had three major risk factors for lead perforation: a history of temporary pacing, anticoagulant use, and regular physical activity, but other risk factors (active fixation lead, female sex, older age, steroid therapy, body mass index of \u0026lt; 20 kg/m\u003csup\u003e2\u003c/sup\u003e, lead long procedure times, and infections) were absent (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The main reason for perforation may be repeated golf swing, because the lead perforated four months after repeated identical swing action. The understanding of the specific mechanism of perforation remains subject to speculation. The action resulted in the electrode being pulled repeatedly, increasing tension, which might have created a strong force per unit area (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) toward the atrial wall, leading to the lead perforation.\u003c/p\u003e\u003cp\u003eThe mechanism responsible for delayed lead perforation has been proposed as a gradual process in which the combination of contracting myocardium, reactive fibrosis, and the lead itself are thought to “self-seal” the heart and the investing visceral pericardium, thereby limiting rapid fluid accumulation and the size of the resulting effusion (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Our patient had markedly high impedance, an increase in capture threshold, and then impedance decreased to normal, with a higher threshold value compared to the early postoperative threshold. Impedance may vary depending on the tissue components around the lead tip, such as muscle, blood (decreased), and air (e.g., lung, pericardial space, and increased) (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The atrial lead tip gradually protruded from the RAA to near the inferior wall of the MRPA and still in the pericardium, and did not penetrate the artery. The tip was then adhered to thrombo-fibrotic lead encapsulations (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) and surrounding myocardium or tissues. Therefore, the process of perforation corresponded to changes in electrical parameters.\u003c/p\u003e\u003cp\u003eThe management of lead perforation includes conservative, surgical, and transvenous lead extraction, depending on the patient’s symptoms, hemodynamic status, and presence of any significant pericardial or pleural effusion, although lead extraction is usually mandated (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Surgical removal is usually considered the preferred strategy (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), but removal by traction under fluoroscopic guidance has also shown to be safe and effective (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). However, a lack of conservative management in part relates to the criteria used for case identification and the definitions chosen for clinically significant cardiac perforation (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Cases where a conservative strategy may be appropriate include those in the absence of perforation-related pain, bleeding, or malfunction, or in which perforation-related symptoms have resolved without significant pericardial effusion, or in which perforations were detected incidentally by CT (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). In most instances, it has been suggested that conservative treatment without removal of the right atrial lead is a viable option for treatment, especially for microdislodgement. When planning a conservative strategy, the patient’s wishes must be considered through an open discussion regarding the potential future risk of complications requiring re-intervention versus the upfront risks of lead revision (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Some studies have reported that anticoagulation status was associated with pericardial tamponade (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Although anticoagulant use of the patient, the lead tip did not penetrate into the artery in the absence of tamponade. Regarding the patient’s preference, chest pain diminished after the mode changed, ventricular pacing parameters were stable, and a conservative approach was finally administered. During a follow-up period of nearly 16 years after implantation, perforation-related symptoms or pericardial effusion were always absent in the patient, in addition to a higher threshold of atrial lead. When pacemaker interrogation monitored energy exhaustion and increased threshold of aging ventricular lead, management options in this patient included placement of new leads in the same pocket with a new pulse generator or leadless pacemaker. The criteria used for case selection remain unclear and are not clearly defined. Considering atrial perforation, energy exhaustion, and two abandoned leads, a leadless pacemaker was eventually implanted, which is the first reported case.\u003c/p\u003e\u003cp\u003eHerein, we describe the first case of leadless pacemaker implantation after delayed atrial lead perforation and pacemaker energy exhaustion. In view of lead perforation, conservative treatment was chosen in the absence of complications during a follow-up period of 16 years. A conservative strategy may be appropriate and feasible for those in the absence of perforation-related complications. For patients with pacemaker energy exhaustion combined with ventricular lead aging after conservative treatment of lead perforation, leadless pacemaker may be an alternative approach.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCorresponding authors:\u0026nbsp;\u003c/strong\u003eJinqiu Liu and Feifei Chen.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll available information is contained within the present manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFundings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the National Natural Science Foundation of China (81700301), Scientific Research Foundation of Education Department of Liaoning Province (LZ2020058), Liaoning Revitalization Talents Program (XLYC2203195) and Scientific Research Project of Dalian Medical Key Specialty “Climbing Peak Plan” (2022DF016).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLiu JQ and Chen FF interpreted the patient data and wrote the manscript. Zhao YC and Su LP collected and analyzed the clinic data. Wang H performed the imaging examination. Gao YC collated the pacemaker data\u0026nbsp;and Luan C draw Figure 2. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eVamos M, Erath JW, Benz AP, et al. Incidence of cardiac perforation with conventional and with leadless pacemaker systems: a systematic review and meta-analysis. J Cardiovasc Electrophysiol 2017;28:336-346. \u003c/li\u003e\n\u003cli\u003eCanoO, Andr\u0026eacute;sA, Alonso P, 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.\u003c/li\u003e\n\u003cli\u003eIssa ZF, Issa TZ. Feasibility and safety of percutaneous lead revision for subacute and delayed cardiac device lead perforation. JACC Clin Electrophysiol 2021;7:26-35.\u003c/li\u003e\n\u003cli\u003eWilkoff BL, Love CJ, Byrd CL, et al. Transvenous lead extraction: Heart Rhythm Society expert consensus on facilities, training, indications, and patient management: this document was endorsed by the American Heart Association (AHA). Heart Rhythm 2009;6:1085-1104.\u003c/li\u003e\n\u003cli\u003eRajkumar CA, Claridge S, Jackson T, et al. Diagnosis and management of iatrogenic cardiac perforation caused by pacemaker and defibrillator leads. Europace 2017;19:1031-1037.\u003c/li\u003e\n\u003cli\u003eZhou X, Ze F, Li D, et al. Outcomes of transvenous lead extraction in patients with lead perforation: A single-center experience. Clin Cardiol 2020;43:386-393. \u003c/li\u003e\n\u003cli\u003eWaddingham PH, Elliott J, Bates A, et al. Iatrogenic cardiac perforation due to pacemaker and defibrillator leads: a contemporary multicentre experience. Europace 2022;24:1824-1833.\u003c/li\u003e\n\u003cli\u003eAcha MR, Rafael A, Keaney JJ, et al. The management of cardiac implantable electronic device lead perforations: a multicentre study. Europace 2019;21: 937-943. \u003c/li\u003e\n\u003cli\u003eLaborderie J, Barandon L, Ploux S, et al. Management of subacute and delayed right ventricular perforation with a pacing or an implantable cardioverter-defibrillator lead. Am J Cardiol 2008;102: 1352-1355.\u003c/li\u003e\n\u003cli\u003eZhang X, Zheng C, Wang P, et al. Assessment of cardiac lead perforation: comparison among chest radiography, transthoracic echocardiography and electrocardiography-gated contrast- enhanced cardiac CT. Eur Radiol 2019;29:963-974.\u003c/li\u003e\n\u003cli\u003eAkbarzadeh MA, Mollazadeh R, Sefidbakht S, et al. Identification and management of right ventricular perforation using pacemaker and cardioverter- defibrillator leads: a case series and mini review. J. Arrhythmia 2017;33:1-5. \u003c/li\u003e\n\u003cli\u003eHaque MA, Roy S, Biswas B. Perforation by permanent pacemaker lead: how late can they occur? Cardiol J 2012;19:326-327.\u003c/li\u003e\n\u003cli\u003eKhan MN, Joseph G, Khaykin Y, et al. Delayed lead perforation: a disturbing trend. Pacing Clin Electrophysiol 2005;28:251-253.\u003c/li\u003e\n\u003cli\u003eAhmed A, Shokr M, Lieberman R. Subacute right ventricular perforation by pacemaker lead causing left-sided hemothorax and epicardial hematoma. Case Rep Cardiol 2017;1264734.\u003c/li\u003e\n\u003cli\u003eKeiler J, Schulze M, Dreger R, et al. Quantitative and qualitative assessment of adhesive thrombo-fibrotic lead encapsulations (TFLE) of pacemaker and ICD leads in arrhythmia patients-A post mortem study. Front Cardiovasc Med 2020;7:602179.\u003c/li\u003e\n\u003cli\u003eSanoussi A, El Nakadi B, Lardinois I, et al. Late right ventricular perforation after permanent pacemaker implantation: how far can the lead go? Pacing Clin Electrophysiol 2005;28:723-725.\u003c/li\u003e\n\u003cli\u003eKusumoto FM, Schoenfeld MH, Wilkoff BL, et al. HRS expert consensus statement on cardiovascular implantable electronic device lead management and extraction. Heart Rhythm 2017;14:e503-e551.\u003c/li\u003e\n\u003cli\u003eMahapatra Srijoy, Bybee Kevin A, Jared Bunch T, et al. Incidence and predictors of cardiac perforation after permanent pacemaker placement. Heart Rhythm 2005;2:907e11.\u003c/li\u003e\n\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":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"lead perforation, leadless pacemaker, conservative approach, energy exhaustion, case report","lastPublishedDoi":"10.21203/rs.3.rs-5171162/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5171162/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDelayed lead perforation is a rare complication of a cardiac implantable electronic device (CIED). Clinical presentations range from completely asymptomatic to pericardial tamponade. Surgical lead extraction is recommended and percutaneous lead extraction with surgical backup is an alternative method.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA male with a history of paroxysmal atrial fibrillation and sick sinus syndrome implanted a dual-chamber pacemaker with two passive fixation lead. He was on oral anticoagulants and played golf for almost 1 hour every day after implantation. However, he complained of thoracic stabbing in the sternal manubrium with abnormal findings on pacemaker interrogation. Imaging confirmed the perforated atrial electrode with lead tip protrusion from the pericardium adjacent to the inferior wall of the main right pulmonary artery, but with no pericardial effusion. A lead removal by transvenous approach with surgical support was suggested, but the patient refused. Given the stable condition of the patient, conservative treatment was chosen in the absence of complications during a follow-up period of 14 years. Then pacemaker energy was exhausted with a ventricular lead threshold increased. A leadless pacemaker was implanted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChest pain in CIED with abnormal electrical parameters, especially ongoing treatment with anticoagulants and regular physical activity, should always raise suspicion of lead perforation. A conservative strategy may be appropriate and feasible for those in the absence of perforation-related complications. For patients with pacemaker energy exhaustion combined with ventricular lead aging after conservative treatment of lead perforation, leadless pacemaker may be an alternative approach.\u003c/p\u003e","manuscriptTitle":"Leadless pacemaker implantation after delayed atrial lead perforation and pacemaker energy exhaustion: A case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-16 16:46:48","doi":"10.21203/rs.3.rs-5171162/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-12-06T12:40:05+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"66583559075894541207914377393122416685","date":"2024-12-03T21:24:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-01T14:45:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-28T14:00:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"6146538327873584474875578846429099564","date":"2024-11-28T13:40:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"291915751891265768511168974434565737911","date":"2024-11-23T08:27:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-02T07:49:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"112613239793517955659240118174437891344","date":"2024-10-26T04:26:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"227815302438478766416801301373462781609","date":"2024-10-25T05:01:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"332957904042441902644067078750624294429","date":"2024-10-24T05:38:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-10-24T01:39:19+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-10-10T18:29:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-08T11:58:52+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-08T11:58:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cardiovascular Disorders","date":"2024-09-28T15:10:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"eb946573-f807-46b6-bfc8-3d8d5dd681cb","owner":[],"postedDate":"December 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-30T15:58:05+00:00","versionOfRecord":{"articleIdentity":"rs-5171162","link":"https://doi.org/10.1186/s12872-024-04448-z","journal":{"identity":"bmc-cardiovascular-disorders","isVorOnly":false,"title":"BMC Cardiovascular Disorders"},"publishedOn":"2024-12-27 15:56:50","publishedOnDateReadable":"December 27th, 2024"},"versionCreatedAt":"2024-12-16 16:46:48","video":"","vorDoi":"10.1186/s12872-024-04448-z","vorDoiUrl":"https://doi.org/10.1186/s12872-024-04448-z","workflowStages":[]},"version":"v1","identity":"rs-5171162","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5171162","identity":"rs-5171162","version":["v1"]},"buildId":"omnImTCwR2MFx8CMYfrG7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}