Presentation
Presenting to the emergency department with chest pain 5 days following elective insertion of AICD. Uncomplicated insertion of dual-chamber device with leads in the right atrial appendage and right ventricle.
Patient Data
Chest x-ray shows left-sided pacemaker with leads projected over the right atrium and the right ventricle.
No pneumothorax.
Chest x-ray 5 days later at ED presentation
The chest x-ray performed while the patient was in the emergency department shows migration of the right ventricular pacing wire - now projected with its tip inferior to the left hemidiaphragm.
No pneumothorax, pleural effusion, or free subdiaphragmatic gas.
Cardiomediastinal contours remain stable.
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The right ventricular pacing lead has migrated distally, passing through the right ventricular wall at the cardiac apex. It passes through the pericardium to abut the left hemidiaphragm anteriorly.
There is no pericardiac effusion and no pneumothorax or pneumomediastinum.
Case Discussion
Perforation of the right ventricle following pacemaker insertion is a rare but life-threatening event.
Acute perforation within 24 hrs is often symptomatic while subacute or chronic perforation may be asymptomatic.
The right ventricular apex is the most common site of perforation due to its thin wall.
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