An unusual case of atrial lead tip perforation – Unrevealing imaging with normal lead parameters!

Atrial lead perforation is a rare complication and can sometimes be missed on diagnostic imaging modalities. We report an unusual case of right atrial (RA) lead tip perforation which was successfully managed with timely intervention. An elderly male who underwent a recent permanent pacemaker implantation (PPI) presented with recurrent relatively slow-filling pericardial effusion with drop in hemoglobin. The diagnostic imaging was unrevealing with normal lead parameters and surgical exploration found atrial lead tip perforation through the RA appendage (RAA) which was subsequently repaired. Cardiac perforation is an uncommon complication of pacemaker and implantable cardioverter defibrillator implantation, with a reported incidence of 0.1%–1%. Active-fixation leads have been associated with a higher incidence of cardiac perforation. Normal lead parameters do not rule out lead tip perforation. Computed tomography often fails to demonstrate minor displacement of atrial leads and a high degree of clinical suspicion is required to guide appropriate intervention for diagnosis and treatment.