Authors: Blanca Santos, Río Aguilar-Torres, Alberto Cecconi, Jorge Salamanca, Lidia Vilches, Emilio Monguío, Hugo Auquilla Luzuriaga, Guillermo Reyes, Fernando Alfonso
Categories: Rhythm Disorders and Electrophysiology, bradycardia, cardiac pacemaker, echocardiography, electrocardiogram, electrophysiology, stroke, ultrasound, ventricular septal defect
Source: JACC Case Reports
Authors: Blanca Santos, Río Aguilar-Torres, Alberto Cecconi, Jorge Salamanca, Lidia Vilches, Emilio Monguío, Hugo Auquilla Luzuriaga, Guillermo Reyes, Fernando Alfonso
Pacemaker lead septal perforation is an uncommon but potentially serious complication. Early identification remains crucial to prevent potential life-threatening events.
A 30-year-old man was admitted with an acute ischemic stroke. Past medical history included a premature pacemaker implantation because of a paroxysmal atrioventricular block, followed by multiple pacemaker-related failures and complications. Nine months before the present admission, a dual-chamber pacemaker with left bundle branch pacing was implanted. At admission, abnormal findings were noted during cardiac rhythm monitoring, and pacemaker interrogation revealed ventricular capture failure. Two-dimensional echocardiography disclosed a septal perforation, with a striking migration of the ventricular lead into the left ventricle. Given the thromboembolic complication, lead removal was indicated. Interestingly, a new tubular “ghost” image was observed on echocardiography after lead removal, with uncertain implications.
Pacemaker septal perforation is very rare but may entail serious risks. Optimal management remains controversial and depends on associated symptoms and complications.
In patients with progressive pacemaker threshold increase, early imaging is key. Lead septal perforation requires careful evaluation given potential associated complications, including thromboembolic risk.
A 30-year-old man was admitted to the emergency department with a sudden onset of global aphasia and facial palsy. Vital signs were stable, blood pressure was 121/61 mm Hg, and heart rate was 49 beats/min. Urgent brain computed tomography angiography revealed a hyperdensity in the M1 segment of the left middle cerebral artery, confirming an acute ischemic stroke. In addition to the culprit occlusion, a small secondary infarction in the left caudate nucleus was found. Mechanical thrombectomy was performed, achieving successful recanalization. However, abnormal findings during cardiac rhythm monitoring were noticed since admission. Complete neurological recovery was ensued within the first 48 hours.Take-Home Messages•In patients with progressive capture threshold increase, particularly in cases of conduction system pacing, early imaging should be considered to rule out septal perforation.•Septal lead perforation with malposition into the left heart is a rare but serious complication that requires careful evaluation given the thromboembolic risk and the complexity of the lead removal procedure.
The patient was incidentally diagnosed at the age of 13 years with a paroxysmal atrioventricular block requiring dual-chamber pacemaker implantation. Within the following years, he recounted 2 episodes of pocket infection, which required transvenous lead extraction. At 18 years of age, he was diagnosed with pacemaker lead–related endocarditis, requiring cardiac surgery and removal of all related hardware, followed by temporary epicardial pacemaker implantation. Subsequently, he was pacemaker-free for several years yet remained completely asymptomatic. Recently, 9 months before the current event, a new dual-chamber pacemaker with left bundle branch pacing (St Jude Tendril TCNSEEL 164931/TC/65F NSEHB018596) was implanted uneventfully at another center.
Given the coexisting history of sudden neurological symptoms, bradycardia, and abnormal cardiac rhythm on monitoring, combined with a history of multiple device-related complications, the differential diagnosis included conditions such as pacing system–related thrombus, undiagnosed thrombogenic arrhythmias, infective endocarditis, thrombophilia, or paradoxical embolism.
The initial electrocardiogram and monitoring recordings showed capture and sensing failures, and chest x-ray showed an apparently adequate position of both leads (considering the ventricular lead as placed in a low septal position), both on posteroanterior and lateral views (Figures 1A and 1B).Figure 1Electrocardiogram and Chest X-Ray at Admission(A) Electrocardiogram at admission showing capture and sensing failures as well as different grades of atrioventricular block. (B) Chest x-ray at admission with no evident lead displacement.
At the time of interrogation, ventricular capture at the highest output energy (7.5 V) was not possible. Pectoral capture was noticed by the patient, but no evoked ventricular potential was documented, either on the intracavitary electrogram or on the conventional surface electrocardiogram. The auricular lead demonstrated normal function. Reviewing past medical records, a slowly progressive capture threshold rise had been already reported, increasing from 0.75 V at the time of implantation to 2.25 V after 6 months, together with a sensing decrease, from 8.1 to 4.3 mV, with impedances remaining stable.
As an initial diagnostic approach, two-dimensional transthoracic echocardiography (TTE) was performed (Figures 2A to 2C). Unexpectedly, a lead septal perforation and malposition was readily visualized, with a striking migration of the ventricular lead through the interventricular septum into the left ventricle. Valve functions were normal. There were no findings suggestive of residual thrombus or other abnormal material related to the lead. To better visualize the perforation and lead displacement and to further rule out additional related complications, transesophageal echocardiography (TEE) was performed (Videos 1 and 2). This technique enabled a more comprehensive visualization of both leads without images suggestive of vegetations or residual thrombus. The presence of a patent foramen ovale or intracardiac shunts was also excluded through detailed 3-dimensional images and contrast echocardiography.Figure 2Findings on Transthoracic and Transesophageal Echocardiography(A and B) Serial TTE images showing septal perforation, with migration of the ventricular lead through the interventricular septum into the left ventricle (yellow arrows). (C) Contrast TTE image showing absence of flow transit to the left cardiac chambers. (D) TEE after lead removal. Tubular image attached to the interventricular septum, known as “ghost” image (yellow dashed arrow). LA = left atrium; LV = left ventricle; RV = right ventricle; TEE = transesophageal echocardiography; TTE = transthoracic echocardiography.
Treatment of lead perforation with dislocation into the left side of the heart remains controversial because of limited data. It usually depends on the time from implantation, associated symptoms, or complications and comorbidities.^1^^,^^2^ However, in the absence of other reasonable explanation, in our patient the stroke was assumed to be a thromboembolic event related to the lead malposition. Therefore, lead removal was indicated. Several options were discussed at the heart team meeting to perform the procedure regarding the preferred approach for lead extraction, as well as the optimal site and safety conditions. Having discarded device infection, it was ultimately decided that a percutaneous lead extraction was the preferred approach.
Extraction was performed in the operating room under general anesthesia by the cardiac surgery team, with extracorporeal circulation on standby in order to address any potential complication. This unique lead location entailed the risk of potentially dangerous complications, including valve damage or iatrogenic ventricular septal defect enlargement. In this regard, TEE guidance was very useful, not only to accurately trace the lead's course inside the heart, but also to rapidly detect the potential development of procedural-related complications. Lead removal was uneventful, with no abnormal flows detected after extraction. However, following the lead's intracardiac route, a new tubular image postremoval was identified attached to the interventricular septum and protruding into the right ventricle, where the lead was previously located (Figure 2D, Video 3). This finding has been previously described after lead extraction and named as “ghost” images, with uncertain prognostic significance and no established management.^3^^,^^4^
After successful and uneventful lead extraction, a new conventional dual-chamber pacemaker was implanted, programmed to minimize ventricular pacing. This strategy was carefully debated given the patient's history of repeated pacemaker-related complications. However, given the initial diagnosis of congenital atrioventricular block with incomplete documentation of its course over the years, the advanced conduction disorder with paroxysmal atrioventricular block reported during the current admission, together with the patient's favorable opinion, the final decision was to proceed with a new device implantation.
The patient was discharged under oral anticoagulation, conditioned to clinical and echocardiographic follow-up.
Clinically, the patient remained asymptomatic and free of embolic events during follow-up. Periodic echocardiographic controls were performed, showing no morphological changes. At the 3-month follow-up, having discarded thrombophilia through a complete hematology panel and with no evident morphological changes in the “ghost” image, oral anticoagulation was discontinued.
We are witnessing a recent increase in the use of conduction system pacing, including left bundle branch area pacing (LBBAP)—either left bundle branch pacing or left ventricular septal pacing—and His bundle pacing, given its advantages over traditional right ventricular apical pacing. These techniques are technically more demanding but are particularly beneficial for patients requiring permanent pacing with a high expected ventricular pacing burden or reduced left ventricular ejection fraction.^1^^,^^2^
LBBAP entails a risk of specific complications related to the ventricular transseptal route of the pacing lead, with an overall complication rate comparable with that reported for cardiac resynchronization therapy implantations.^5^ The risk of acute septal perforation associated with LBBAP is 3.67%, as described in the MELOS (European Left Bundle Branch Area Pacing Outcomes Study), the largest available registry study.^5^ It is typically recognized intraprocedurally and, when addressed promptly, usually resolves just by lead repositioning, with no long-term consequences.^6^ The risk of delayed or late septal perforation during follow-up, as illustrated in the current case, is extremely low. Based on the MELOS study, delayed perforation into the left ventricle is observed in 0.08%, comparable to that reported in previous studies. However, no strokes associated to this concrete complication have been reported to date.5, 6, 7 (Table 1).Table 1Previously Reported Evidence Concerning Late LBBAP Lead Perforation CasesCase delayed septal perforation after LBBAP Kim et al (2024)^7^Septal lead perforation 24 hours postimplantation. Routine TTE revealed a thrombus in aortomitral curtain in the left ventricular outflow tract. Patient remained asymptomatic. Vinther et al (2024)^11^Septal lead perforation detected 12 days postimplantation due to 2 appropriate shocks on ventricular fibrillation. TTE confirmed that the lead tip was in the left ventricle leading to mechanically induced premature beats that initiated ventricular fibrillation. Ravi et al (2020)^12^First septal lead perforation described with LBBAP. Two weeks postimplantation, the patient presented with presyncope in which threshold rise was detected. Hsieh et al (2023)^13^Lead septal perforation on the first night postimplantation presenting as sustained ventricular tachycardia.Registry study Jastrzębski et al (2022)^5^Large international registry–based observational study that assessed outcomes of LBBAP in 2,533 patients. Delayed perforation into the left ventricle was observed in 2 cases, without additional details.LBBAP = left bundle branch area pacing; TTE = transthoracic echocardiography.
Current guidelines from the European Society of Cardiology and the Heart Rhythm Society provide limited specific recommendations regarding the management of ventricular lead perforation with malposition into the left heart chambers, as this is a very rare and often underdiagnosed complication.^2^^,^^8^^,^^9^ However, both scientific societies highlight the importance of cardiac imaging for accurate lead localization and thromboembolic risk evaluation.^2^^,^^8^^,^^9^
As previously mentioned, delayed septal perforation has been reported as a specific LBBAP-related complication, and isolated case reports have documented its association with arrhythmic or thrombotic complications.5, 6, 7 However, to the best of our knowledge, the current case represents the first description of delayed LBBAP septal perforation associated with a thromboembolic stroke. In our case, the identification of the lead perforation, together with the presence of an acute ischemic stroke and absence of other embolic sources, strongly suggested a causal relationship, despite the absence of a culprit thrombus on imaging.
All of these cases require an individualized approach, taking into consideration the time at which malposition is diagnosed (lead endothelization and thrombus formation may complicate late extractions), feasibility of the removal and procedural risks, symptoms and associated comorbidities^1^^,^^2^^,^^7^^,^^10^ In our patient, with an abrupt thromboembolic presentation and an acceptable procedural risk, having excluded device-related endocarditis, lead removal was the preferred approach.
Regarding oral anticoagulation, treatment of left ventricular lead misplacement discovered late after implantation includes either chronic anticoagulation (when the embolic source remains unclear or when extraction is not feasible or high risk) or lead removal, to prevent thromboemboli.^1^^,^^2^^,^^10^ However, the indication of oral anticoagulation in our particular clinical setting, having removed the potential embolic source, is not well established. The decision to initiate oral anticoagulation postextraction reflects a cautious strategy in a context where clinical evidence remains scarce. In addition, to further ensure that the tubular “ghost” image was not indeed a thrombus, discontinuation of anticoagulation was conditioned to echocardiographic follow-up.
The identification of postextraction “ghost” structures remains a controversial finding. They are considered benign remnants of fibrotic tissue that initially covered the lead but appear to be unrelated to adverse events.^3^^,^^4^
This case illustrates the need for individualized clinical decision-making in rare pacing-related complications and highlights current evidence gaps.
Pacemaker lead septal perforation with left ventricular misplacement can be readily diagnosed with TTE. Treatment remains controversial because of limited data, but when related to a thromboembolic event, lead extraction should be considered as the treatment of choice. This unique perforation location entails a risk of dangerous complications, and TTE and TEE guidance remain essential to perform secure lead removal.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.