Punctured right ventricle by pacemaker lead
Presents with severe left sided chest pain with diaphoresis, on background of a primary prevention ICD insertion 2 weeks ago for idiopathic dilated cardiomyopathy. He describes the pain has jolting, episodic, radiating to the L shoulder and associated with deep breathing. His ECG shows normal sinus rhythm with occasional ventricular ectopics, and his troponin was negative. A CTPA was performed.
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ICD lead migrated through pericardium with the tip adjacent to the 5th rib.
Filling defect is present within the left upper lobar artery extending segmentally. The remaining pulmonary arteries opacify normally. There is no ventricular septal deviation. The heart is mildly enlarged. No pericardial effusion is identified.
There is atelectasis in the dependent portions of the lungs, most pronounced at the lung bases. No pleural effusion is demonstrated.
Unfortunately this finding was missing in the radiology report, which only commented on the PE. Subsequently the patient's ICD was interrogated and found that the lead was likely misplaced (as it was not sensing correctly), and that the patient's pain corresponded with the pacing spikes of the ICD. When the ICD was turned off, the patient's pain had resolved.
The patient had received rivaroxaban for treatment of his left sided PE in the Emergency Department. On review, it was felt that the patient's symptom was not attributable to the PE, but rather from diaphragmatic stimulation. As an unifying diagnosis, the source of PE was most likely from the right ventricle which was punctured by the ICD lead. Fortunately the patient did not develop signs of hemopericardium overnight whilst monitored. He was transferred to a cardiothoracic center the next day for definitive management.