Implantable cardioverter-defibrillator with cardiac perforation

Case contributed by Dr Ammar Ashraf

Presentation

History of ICD insertion for recurrent syncope and ventricular tachyarrhythmia. The next day, the patient had vasovagal syncope and bradycardia (heart rate =25 bpm) and ICD did not pace.

Patient Data

Age: 70 years
Gender: Male

Baseline chest x-ray after ICD insertion

X-ray

A single chamber ICD is seen with its tip is not in place; its tip position cannot be confidently accessed on this single supine frontal view.

Interval development of small left pleural effusion with mild left basal atelectatic changes. An ICD is seen in place with its tip lying in the cardiac apical region. 

ICD lead is penetrating through the right ventricle and its tip is lying outside the heart within the soft tissues of the left anterior chest wall just above the upper border of the left 6th rib costochondral junction. No pericardial effusion is seen. Minimal pleural reaction is noted in the left costophrenic angle and mild atelectatic changes are seen in both lower lobes.

Case Discussion

  • The vasovagal syncope and bradycardia were managed medically (Atropine & dopamine). The case was discussed with the cardiac surgeon in our local cardiac surgery center and patient was shifted there in a stable condition for further management. 
  • Cardiac perforation is commonly identified at the time of insertion; however, it can present as a late complication. The incidence of perforation is higher with ICD insertion (~ 5%) than with pacemaker insertion (<1%) 1. Perforation should be suspected on chest radiograph, particularly if the ICD lead is projecting beyond the boundaries of the heart 1,2. CT (ECG gated CT, preferably in the diastolic phase) is superior to the chest radiography in the exact localization of the lead position 1,2.

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