Anesthetic management of high-risk transvenous lead extraction for right ventricular perforation: A case report

Right ventricular (RV) perforation by a pacemaker lead is an uncommon but potentially catastrophic complication. A 90-year-old man with atrial fibrillation on apixaban, vascular dementia, prior stroke with no residual deficits, insulin-treated type 2 diabetes mellitus, and complete heart block status post Boston Scientific dual-chamber pacemaker in August 2024 presented with chest pain and palpitations with junctional bradycardia at a rate of mid to high 30s. Cardiac computed tomography (CT) with contrast demonstrated the RV lead tip extending beyond the myocardium into the epicardial fat without pericardial effusion; transthoracic echocardiography (TTE) showed preserved biventricular function (LVEF 50–55 %) and mild pulmonary hypertension (estimated PASP 45 mmHg). Multidisciplinary risk stratification deemed the case high-risk; the extraction was performed in a cardiac operating room (OR) under general anesthesia with invasive monitoring and continuous transesophageal echocardiography (TEE). A predefined bailout plan included surgical and perfusion standby and immediate availability of blood products including packed red blood cells (pRBC) and four factor prothrombin complex concentrate (4F-PCC). The lead was removed percutaneously without hemodynamic instability or pericardial effusion on TEE surveillance. The patient recovered uneventfully. This case emphasizes (1) the value of CT to confirm extracardiac lead position and guide planning, (2) the anesthesiologist's role in real-time TEE surveillance and team choreography during high-risk steps, and (3) readiness for catastrophic cardiac or vascular injury with multidisciplinary planning and standby.