Images and Case Reports in Arrhythmia and Electrophysiology Right Coronary Artery Fistula as a Result of Delayed Right Atrial Perforation by a Passive Fixation Lead

Delayed lead perforation (DLP) is an uncommon complication of permanent pacemaker and defibrillator implantation, especially that of the right atrium (RA).1 Lead perforation is considered delayed when it occurs 30 days after implantation. The incidence of DLP has been reported to be 0.8% and is more common in elderly individuals.1,2 With the yearly increase in implanted devices, and the advance in imaging modalities, this complication is more likely to be encountered. To our knowledge, delayed right atrial perforation involving a passive fixation lead remains extremely rare and has never been reported. We describe a case of an asymptomatic right atrial DLP resulting in a pseudoaneurysm and right coronary artery (RCA) fistula, diagnosed incidentally 53 months after the implantation of a passive atrial lead. Our patient is a 67-year-old man with a medical history of hypertension, diabetes mellitus, end-stage renal disease on hemodialysis, coronary artery bypass grafting, and ischemic cardiomyopathy. The patient had a dual-chamber implantable cardioverter-defibrillator implanted for primary prevention of sudden cardiac death. A passive fixation lead (5594 CapSureR SP Novus, Medtronic; Indianapolis, IN) was implanted in the RA appendage, and the right ventricular lead (6949 Sprint Fidelis, Medtronic) was implanted in the apical septum without difficulty. The initial atrial pacing threshold was 0.5 V at 0.4 ms and 1.5 V at 0.4 ms for the ventricular lead. The initial parameters remained unchanged at regular 4-month follow-ups for the first 2 years. At the 2-year follow-up visit, the RA pacing threshold increased to 1 V at 0.5 ms and progressed to 1.5 V at 0.5 ms 3 months later. A serial chest x-ray film did not show any change in the lead position during or after this period (Figure 1). Unknown to us, the patient underwent a noncontrast computed tomographic (CT) scan of the chest in the pulmonary clinic for pulmonary nodules during the same period. The scan showed an 4.5-cm mass at the level of the atrioventricular groove in the vicinity of the right atrial lead. During a regular visit 4 years after implantation, implantable cardioverter-defibrillator telemetry showed long episodes of nonsustained ventricular tachycardia. Because of this finding, the patient underwent elective coronary angiography to assess graft patency. Coronary angiography revealed total occlusions of native coronary vessels and an occluded saphenous graft to the RCA. While injecting the native RCA, an unusual filling mass was noticed. This mass was 7 4 cm, had a saclike appearance with slow clearance of the contrast, and appeared to communicate with the RCA through a fistula. The right atrial lead of the implantable cardioverterdefibrillator appeared to be in contact with the mass on cine angiography images (Figure 2). A multidetector cardiac CT scan confirmed that the lead tip was perforating the RA and protruding into the anterior margin of the mass. The mass measured 7.1 5 cm on this CT scan. Because of the interval increase in the size of the mass, the patient underwent surgery. An intraoperative transesophageal echocardiogram further defined the mass (Figure 3). On surgical exploration, the mass was confirmed to be a right atrial perforation, with a pseudoaneurysm secondary to lead perforation (Figure 4). The surgical procedure consisted of ligation of the RCA, evacuation of the pseudoaneurysm from the thrombus, resection of the distal right atrial lead, and closure of the right atrial perforation. The patient did well postoperatively. Figure 1. Anteroposterior and lateral views of the chest x-ray film showing stable position of the leads at 4 years after implantation.