Delayed right ventricular perforation 3 years after permanent pacemaker implantation: a case report

Introduction: Right ventricular (RV) lead perforation is an uncommon but serious complication of pacemaker implantation. Most cases occur acutely or subacutely, while very late perforations – beyond 1 year – are exceedingly rare and often unexpected. Presentation of case: We report the case of a 53-year-old woman who presented with syncope and cardiac arrest 3 years after permanent pacemaker implantation. Imaging revealed cardiac tamponade due to RV lead perforation. The patient underwent emergency median sternotomy, lead extraction, and RV repair without the use of cardiopulmonary bypass. Postoperatively, spontaneous sinus rhythm was preserved, and pacemaker reimplantation was not required. Discussion: Very late lead perforation is rarely reported, especially in young patients without risk factors. This case highlights the unpredictable nature of the complication, the value of contrast-enhanced CT in diagnosis, and key surgical considerations, including when bypass may be avoided and when reimplantation is unnecessary. Conclusion: This case emphasizes the importance of long-term surveillance in pacemaker recipients and individualized management strategies for delayed RV lead perforation.