Delayed asymptomatic migration of an implantable cardioverter-defibrillator lead to the costophrenic angle

The figure shows a single-chamber defibrillator [implantable cardioverter-defibrillator (ICD)] with a dual-coil, passive-fixation lead (Riata 1570, St Jude Medical, MN, USA) perforating the right ventricular apex with migration of the electrode-tip to the costophrenic angle, as suggested by the chest X-ray ( Panel A ) and confirmed by the computed tomographic (CT) scan ( Panels B and C ). This event occurred subacutely in a 70-year-old woman implanted in secondary prevention for non-ischaemic dilated cardiomyopathy. It was diagnosed 3 months after ICD implantation (lack of ventricular sensing/capture) without the presence of any symptom or ICD-related finding (recording of false ventricular tachycardia and/or diaphragmatic stimulation). Lead repositioning was performed in the electrophysiology lab ( Panel D ) without acute/late complications. Delayed perforation is probably not so rare if we consider subclinical events reported in CT studies without modification of pacing/ICD systems performance, but it can be associated with major clinical manifestations: inappropriate shock, abdominal pain, diaphragm stimulation, chest pain, syncope, and tamponade. However, considering the potential risk of similar events, strategies targeted at preventing perforation (e.g. placement of the lead towards interventricular septum, especially in patients at higher risk of perforation) and avoiding delayed diagnosis, like adopting telemonitoring systems, could help in reducing possible complications. Conflict of interest: none declared.