Archived case 178 · April 30-May 7, 2015
Malpositioned ICD Lead-Myocardial Perforation
Middle-aged male with AICD placed several months ago at another facility complains of AICD now delivering inappropriate shocks
The question posed to readers
What are the pertinent radiologic findings if any? What would be the next appropriate course of management?
Imaging findings
Radiologic Findings PA (Fig. 1A) and lateral (Fig. 1B) chest radiographs show a left subclavian trans-venous approach implantable cardioverter defibrillator (ICD) device. The proximal lead overlies the right atrium as expected. The distal shocking or defibrillating lead follows an anomalous and extra-cardiac course extending the confines of the cardiac silhouette perforating the right ventricle (Fig. 1B) subsequently confirmed on an unenhanced CT (not illustrated). Note the left pleural effusion blunting the posterior sulcus on the lateral exam (Fig. 1B). Answer Diagnosis: Malpositioned ICD Lead-Myocardial Perforation
Diagnosis
Malpositioned ICD Lead-Myocardial Perforation
Differential Diagnosis
None
Discussion
More than 250,000 pacemakers and cardioverter-defibrillating devices are implanted each year in the USA alone. As the number of implants deployed increase so do the number of complications associated with their deployment. Not unexpectedly, myocardial perforation rates are higher with ICD’s than pacemakers.
Pacemaker lead perforation rate is on the order of 0.1-0.8% whereas ICD lead perforation rates range between 0.6–5.2%. Lead perforation may be acute (i.e., within the 1st 24 hours following deployment); subacute (within the1st month after deployment) or chronic (more than a month following deployment). Most patients with Subacute or chronic perforations are asymptomatic and the asymptomatic perforation rate is higher than symptomatic perforation rate (15%). Symptoms may include chest pain, inappropriate device firing, failure of the device to capture appropriately, etc.
Potential Causes of Myocardial Lead Perforation:
· Excessive looping or tension on the lead(s)
· Growing prevalence of thinner dilated cardiac chambers with impaired systolic function
· Recent MI (esp. inferior LV wall or RV wall)
· Coronary artery disease
Predictors of Lead Perforation:
· Temporary leads (typically stiffer)
· Atrial leads
· ICD leads
· Increasing shocks delivered by ICD
· Steroid use
· Low body mass index (< 20 kg/m2)
· Older age and female sex
· Anticoagulation therapy
Imaging
· CT is the accepted gold standard imaging modality for the evaluation of suspected lead perforation
· Used to assess depth of lead perforation and extent (> 5 mm into pleuropericardial fat pad)
· Used to assess complications (e.g., hemopericardium; hemothorax)
Management
· Device-lead repositioning and or replacement
· Hemopericardium-hemothorax evacuation when indicated
· Surgical repair-select cases
Selected Readings
1. Burney K, Burchard F, Papouchado M, Wilde P. Cardiac Pacing Systems and Implantable Cardiac Defibrillators (ICDs): A Radiological Perspective of Equipment, Anatomy and Complications. Clin Radiol. 2004; 59:699–708.
2. Hirschl D, Jain VR, Spindola Franco H, et al. Prevalence and Characterization of Asymptomatic Pacemaker and ICD Lead Perforation on CT. PACE. 2007; 30: 28–32.
3. Piekarz J, Lelakowski J, Rydlewska A, Majewski J. Heart Perforation in Patients with Permanent Cardiac Pacing – Personal Observations. Arch Med Sci. 2012; 8:70–74.Original case written by its authors at Virginia Commonwealth University and published at this address as part of a weekly teaching collection. Reproduced here as an archive.