Surgical management of left bundle branch pacing lead causing septal and left ventricular perforation

Key Teaching Points•Right ventricular lead perforation of the interventricular septum and left free wall after bundle branch pacing wire placement can be a life-threatening event that requires prompt intervention.•The clinical presentation right septal vary depending on tip location, type, extent perforation, injury to or walls, surrounding anatomic structures.•As prevalence implantable cardiac pacemaker devices increases new biventricular techniques requiring fixation grow, multidisciplinary teams surgeons, cardiologists, emergency room physicians need promptly recognize deal with sequelae complications these technologies. •Right Despite improvements in procedural technique design, has 3%–9% complication rate, largely owing displacement, myocardial pneumothorax.1Cantillon D.J. Exner D.V. Badie N. et al.Complications health care costs associated transvenous pacemakers nationwide assessment.JACC Clin Electrophysiol. 2017; 3: 1296-1305Crossref PubMed Scopus (53) Google Scholar While (RV) RV is well documented, not. Recently, (LBBP) effected by mid replacing coronary sinus for synchronous patients low ejection fraction. LBBP more closely approximates physiologic conduction presents an alternative unfavorable anatomy, ineffective scarring, occlusions following revisions.2Fink T. Eitz Sohns C. Sommer P. Imnadze G. Left-bundle as bail-out strategy failed resynchronization: case report.Eur Heart J Case Rep. 2022; 6: ytac375Crossref (0) We describe unique newly placed perforating septum, wall, pericardium. The trajectory lacerated lower lobe lung, embedded chest severing sixth intercostal artery, recipient presenting massive hemorrhage, hemopericardium, hemothorax. was surgically removed. This one few reported cases significant bleeding hemodynamic instability secondary from should recognized strategies pacing. An 84-year-old white female patient underwent atrial (RA) at community hospital intermittent third-degree atrioventricular (AV) block Active-fixation, exposed helix screw leads were RA (CapSureFix Novus MRI SureScan 5076-45, diameter 2.0 mm; Medtronic, Minneapolis, MN) using 7F Safe Sheath (Medtronic) stylet, 5076-52, Medtronic) (Medtronic), fluoroscopic guidance outflow tract, repositioning straight stylet into midventricular LBBP. Leads connected dual-chamber Azure S DR (Medtronic). Before discharge without anticoagulation, wave amplitude 1.5 mV, threshold 0.6 V 0.4 ms impedance 551 ohms. 11.9 0.5 684 Electrocardiography confirmed deep LBBB pacing, radiograph (CXR) demonstrated distal (Figure 1A 1B ). Eight days placement, she presented pain near-syncope, but discharged her electrocardiogram showed 70 beats per minute 90% capture. At time, CXR suggested slight 1C). She returned day syncopal fall failure AV bradycardia 2A), systolic blood pressure mm Hg, hematocrit 17%. Chest computed tomography revealed hemopericardium large hemothorax, complete lung collapse, outside heart 2B). A tube drained 3.5 liters bright red blood, ongoing output. follow-up persistent opacification hemithorax 2C). urgently transferred our hospital, having received 6 units packed cells. During transport, patient’s additional 1600 mL suggesting arterial source. Upon arrival, hypotensive confused, substernal pain. Focused assessment sonography trauma echocardiographic signs tamponade. Pacemaker interrogation no capture maximal threshold. Urgent tomography, done because images unobtainable, exit anterolateral ventricle, traversing hemithorax, terminating level space 3A), where there active extravasation contrast within loculated hemothorax 3B). required transfusion 4 cells, 2 fresh frozen plasma, 1 unit platelets, cryoprecipitate taken emergently operating control bleeding. After median sternotomy, pericardium opened 900 clot There lateral anterior descending artery exited 3C). perforated laceration surface, leading air leak parenchymal pacer impaled which actively Intraoperatively, clots removed chest. pocket opened, cut proximal portion gentle traction. Transesophageal echocardiography intraoperative digital palpation normal thickness. puncture site closed single pledgeted, polypropylene horizontal mattress suture both sides approximating myocardium this vessel while preserving patency. end extracted pleural spurting oversewn. oversewing parenchyma 5-0 suture. Temporary epicardial tunneled external pacemaker. extubated, weaned off pressors postoperative 1, Micra leadless 6. visit weeks discharge, had parameters symptoms. Cardiac are tolerated, rates between 3% 9% first month implantation.1Cantillon Lead rare approximately 0.1%–0.8% 0.6%–5.2% defibrillators.3Banaszewski M. Stępińska J. Right leads.Arch Med Sci. 2012; 8: 11-13Crossref (31) Acute occurs less frequently than most common apex ventricle.3Banaszewski Scholar,4Satomi Enta K. Otsuka Ishii Y. Asano R. Sawa S. Left lead: 2021; 5: ytab125Crossref (2) migration cavity have been described; however, resulting extremely rare, only 3 literature past 50 years.4Satomi Scholar, 5Mililis Saplaouras A. Konstantinidou E. al.A complication: abutting through ventricle septum.Pacing 2023; 46: 261-263Crossref 6Iribarne Sangha R.S. Bostock I.C. Rothstein E.S. McCullough J.N. pleura, managed open surgical approach.HeartRhythm 2018; 4: 397-400Abstract Full Text PDF (7) To knowledge, resulted simultaneous wall. drastically timing, structures.7Otaal P.S. Budakoty Kumar Singhal M.K. Hemopneumothorax due subacute subtle presentation.J Family Prim Care. 11: 780-783Crossref Although pain, dyspnea, dizziness, syncope commonly symptoms, may asymptomatic.4Satomi Scholar,8Nichols Berger Joseph Datta D. Subacute shock.Case Rep Cardiol. 2015; 2015983930PubMed alter thresholds result lack capture, unmasking underlying arrhythmias, death.8Nichols Damage adjacent structures cause complications, including pneumothorax, tamponade.7Otaal Since perforations heterogeneous presentations highly morbid clinicians maintain high index suspicion who present history recent loss drop hematocrit. In case, LBBP, setting block. As His rapidly treatment failure,9Liu Wang Q. Sun H. Qin X. Zheng pacing: current knowledge future prospects.Front Cardiovasc Med. 8630399Google we suspect types will future. pathophysiology not clearly defined likely multifactorial related imbalances forces.8Nichols Risk factors include sex, increased age, fragility, short stature, body mass index, decreased thickness, unremoved nonfunctional wires, depressed fraction, use steroids. Pulmonary hypertension subsequent hypertrophy perforation.8Nichols did thickness palpation, elderly fraction (35%), (18.0), frailty, stature (155 cm tall). presyncope when occurred. also contributed migration. risk correlated characteristics, active-fixation leads, small diameter, apical excessive manipulation pocket, referred Twiddler’s syndrome.5Mililis grows United States, providers prepared Because heterogenous despite its being placement. Recognition wires perforate circuitous pattern chest, crucial expeditious repair unstable patient.