Apical Lead Position Increases the Risk of Right Ventricular Lead Perforation: A Retrospective Cohort Study

BACKGROUND: Right ventricular (RV) lead perforation is a rare but potentially life-threatening complication of cardiac implantable electronic devices. Although apical lead placement has been proposed as a risk factor, its clinical significance remains uncertain. This study evaluated whether apical RV lead positioning increases perforation risk and characterized the clinical features, diagnosis, and outcomes of affected patients. METHODS: We retrospectively reviewed data from 1,923 patients who underwent RV lead implantation between January 2002 and June 2023. Patients were categorized into Apex and Non-apex groups according to lead tip location. RV lead perforation cases were identified based on chest radiography findings. Baseline characteristics and the incidence and management of lead perforation were analyzed. RESULTS: Among the 1,923 patients, 503 (26.2%) were assigned to the Apex group and 1,420 (73.8%) to the Non-apex group. RV lead perforation occurred in 5 patients (0.26%): 4 in the Apex group and 1 in the Non-apex group (0.79% vs. 0.07%, p = 0.018). Perforations were diagnosed intraoperatively or within 1-3 days post-implantation, primarily using chest computed tomography. Clinical presentations ranged from asymptomatic findings to chest pain. All patients underwent percutaneous RV lead extraction and revision, without major complications. CONCLUSION: Apical RV lead positioning was significantly associated with an increased risk of lead perforation. Although perforation was uncommon, prompt diagnosis and individualized management ensured favorable outcomes. Careful attention to lead tip location during implantation may help mitigate this risk. Given the small number of events, this finding should be interpreted as hypothesis-generating.