'Spear' through the right ventricle: pericardial tamponade caused by delayed pacemaker lead-related perforation of a normal thickness free wall which was managed percutaneously using the same lead.

To cite: Vasavada A, Vinchurkar M, Agrawal N, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2013202665 DESCRIPTION Lead perforation is seen in around 0.1–1% 2 of pacemaker implantation and is predominantly seen early in the course while occurrence after 1 month is much rarer. A 58-year-old patient who had undergone implantation of a single-chambered VVI pacemaker using an active fixation lead more than 3 months ago for the presence of intermittent complete atrioventricular block presented with symptoms of progressively increasing dyspnoea and fatigue since the past 3–4 days. The patient was diagnosed to have pericardial tamponade (video 1, figures 1 and 2) due to perforation of the normal thickness right ventricular (RV) free wall by the lead which appeared to have passed through the free wall like a ‘spear’ through the endocardium into the pericardial space (videos 2 and 3, figure 3). The patient underwent emergency pericardiocentesis during which around 350 mL of sanguineous pericardial fluid was drained (video 4, figure 4). The patient subsequently underwent repositioning of the same lead which was fixed to the septal position. Subsequent echocardiograms showed no further fluid recollection. This case forms an interesting example of a delayed lead perforation leading to a lifethreatening acute pericardial tamponade in a patient undergoing active fixation lead implantation without most of the other conventional risk factors