Comments

• cardiac perforation after pacemaker implantation is an infrequent complication (incidence less than 1%)
• cardiac perforation can be acute (within twenty-four hours), subacute (within one month) or chronic (after one month)
• risk factors for cardiac perforation include temporary pacemaker implantation, older age, female sex, low body-mass index, use of corticosteroid and anticoagulants and longer fluoroscopy times
• a perforated lead tip can be located in pericardial space, extracardiac free space, mediastinum, lung or chest wall muscles
• pacing parameter changes are dependent on the location of the lead tip; permanent or non-permanent capture failures (increased pacing threshold) and sensing failures are frequent; impedance is variable (depends on the tissue components such as muscle, blood and air)
• clinical manifestations are variable ranging from asymptomatic patients (15% of patients with pacemaker lead perforation) to life-threatening situations
•  pacemaker-dependent patients may experience bradycardia-related symptoms (sudden death, cardiogenic shock, syncope, dizziness, exertional dyspnea …)
• a pleural or pericardial effusion may develop as an associated finding
• myocardial perforation may be identified on chest X-ray by the unusual course of the lead or abnormal position of the tip electrode; lead tip migration may sometimes be too subtle to get definite diagnosis; diagnosis is easier when lead migration outside the cardiac silhouette is observed
•  CT scan is becoming the gold standard in diagnosis of cardiac perforation and lead tip visualization and can be performed when other modalities are nondiagnostic