Cardiac perforation complicating cardiac electrophysiology procedures: value of angiography and use of a closure device to avoid cardiac surgery.

Background: Computed tomography (CT) is used for the diagnosis of cardiac perforation (CP) although it has significant limitations. We report our experience with angiography to assist in the diagnosis and management of cardiac perforation during electrophysiology procedures.
Methods: Patients with suspected CP after pacemaker lead insertion (temporary = 2, permanent = 2) or during epicardial mapping/ablation (n = 2) were included. All patients underwent initial angiography with repeat study performed post-lead repositioning/withdrawal for the pacemaker cases. Patients with CP due to permanent pacing leads underwent CT comparison.
Results: In 4 pacemaker patients, temporary leads caused two acute perforations, permanent active fixation leads caused one subacute right ventricular perforation and one delayed right atrial perforation. CT overdiagnosed CP in one temporary pacemaker patient, and was non-diagnostic in an atrial lead perforation, whereas angiography was accurate in both. Angiography identified an active leak in atrial lead CP, guided percutaneous closure in one case and demonstrated sealing of perforation in all cases. In the 2 epicardial ablation cases, 1 patient underwent surgical repair after a persistent right ventricular perforation, but the other avoided surgery with novel use of an Amplazter® patent ductus arteriosus (PDA) closure device (Abbott, St Paul, MN, USA).
Conclusions: Angiography may be more accurate than CT in the diagnosis of CP. Angiography is easy to perform, can be done acutely, reveals active leaks and can demonstrate sealing of perforations after percutaneous lead repositioning. Utilisation of a PDA closure device may avoid the need for surgery for RV perforation.