Minimal Cardiac Perforation by Lead Pacemaker Complicated with Pericardial Effusion and Impending Tamponade: Optimal Management with No Pericardiocentesis Driven by Echocardiography

Figure 1. Pericardial effusion time course by transthoracic echocardiography. The upper part of the figure illustrates an m-mode at the mitral valve level before lead repositioning. The pericardial effusion (Per E) is evident, revealing a moderate-severe amount (>2 cm separation of the pericardial layers, that appears even larger toward the apex, as evident in the 2-D guiding image at the top of the screen); there is also sign of tamponade, revealed by the protodiastolic collapse of the free wall of the right ventricle (inward motion, identified by the vertical arrows), as it occurs during mitral valve opening (D–E slope) (the vertical dashed lines define the protodiastolic phase). The lower part of the figure is the same view 24 days after the lead repositioning. The pericardial effusion is totally gone. RV = right ventricle; LV = left ventricle; RVFW = right ventricle free wall; IVS = inter-ventricular septum; MV = mitral valve; Per E = pericardial effusion; PLW = posterior wall of left ventricle; Ple E = pleural effusion.

Figure 2. Right ventricular perforation by the ICD lead, visualized by transthoracic echocardiography, before and after lead repositioning. The upper part shows the modified 4-chamber view (the specific inclination of the tomographic plane to attain this plane is schematically shown in the diagram at the bottom left, where the dashed-line-delimited plane indicates the standard 4-chamber view plane orientation), that shows the tip of the wire (due to its minuscule structure, actually the helix) penetrating 2–3 mm into the fluid-filled pericardial space (on the upper left side, a photo of the distal part of the lead is reported, with its characteristics indicated: helix, the fixating screw (long arrow), tip electrode (short arrow), ring electrode (arrow head), and the distal defibrillator electrode (bracket)). The lower part shows the same echocardiographic view after unscrewing the helix, along with minimal lead retraction: no more protrusion of the lead into the pericardial space is visible; in addition, some hypereflective zones along the lead are visible by echo, that should correspond to the electrodes (arrow heads) and coils (arrows). RV = right ventricle; Per E = pericardial effusion.