Pacemaker Lead Perforation Leading to Cardiac Tamponade and Subsequent Anterior STEMI

BACKGROUND: Pacemaker lead perforation is an uncommon but potentially fatal complication of cardiac implantable electronic devices, particularly when hemopericardium and tamponade occur in patients requiring antithrombotic therapy. CASE REPORT: A 74-year-old woman with atrial fibrillation on apixaban and a recent dual-chamber pacemaker implantation presented with dizziness, falling, and dysarthria; her brain computed tomography was negative. She developed syncope with a 6-second ventricular pause and enlarging pericardial effusion and an emergent surgical pericardial window with drainage of 350 mL of hemorrhagic fluid, confirming right ventricular lead perforation left in situ. Shortly after stabilization, she developed anterior ST-segment elevation myocardial infarction because of proximal left anterior descending artery occlusion that was treated with percutaneous coronary intervention. Echocardiogram showed a left ventricular ejection fraction of 35% to 40% without recurrent effusion. CONCLUSIONS: Early recognition, prompt drainage, and careful balancing of bleeding and thrombosis risks are essential; multidisciplinary management enables favorable outcomes. TAKE-HOME MESSAGE: Maintain suspicion for lead perforation despite a normal device interrogation, and act rapidly in the event of tamponade while coordinating multidisciplinary care.