Percutaneous lead extraction and repositioning: An effective and safe therapeutic strategy for early ventricular lead perforation with dislocation both inside and outside the pericardial sac following a cardiac device implantation

Introduction Cardiac perforation of the right ventricle associated with pacemaker or implantable cardioverter defibrillator (ICD) leads' implantation is uncommon, albeit potentially life-threatening, complication. The aim of this study is to further identify the optimal therapeutic strategy, especially when lead dislocation has occurred outside the pericardial sac. Methods and results The study population included 10 consecutive patients (six female, mean age: 66.5 years old) diagnosed with early ventricular lead perforation following a pacemaker or ICD implantation, with significant protrusion inside the pericardial sac (n = 2) or migration of the lead at the pleural space ( n = 3), the diaphragm ( n = 1), or the abdominal cavity ( n = 4), during the period 2013-2017. All patients were symptomatic; however, individuals presenting with hemodynamic instability were excluded. The outcome of the percutaneous therapeutic approach was retrospectively assessed. All patients underwent a successful removal of the perforating lead percutaneously at the electrophysiology lab, by direct traction, and repositioning in another location of the right ventricle. The operation was performed by a multidisciplinary team, under continuous hemodynamic and transesophageal echocardiographic monitoring and cardiac surgical backup. The periprocedural period was uneventful. Subjects were followed up for at least 1 year. Interestingly, all patients developed a type of postcardiac injury syndrome, successfully treated with a 3-month regimen of ibuprofen and colchicine. Conclusion Percutaneous traction and repositioning of the perforating ventricular lead are effective, safe, and less invasive compared with the thoracotomy method in hemodynamically stable patients when dislocation has occurred outside the pericardial sac provided that there is no visceral organs injury.