Published online Mar 6, 2023. doi: 10.12998/wjcc.v11.i7.1615
Peer-review started: November 24, 2022
First decision: December 13, 2022
Revised: December 17, 2022
Accepted: February 10, 2023
Article in press: February 10, 2023
Published online: March 6, 2023
Processing time: 97 Days and 23.1 Hours
Pacemaker lead-induced heart perforation is a rare but life-threatening complication of pacemaker implantation, and timely diagnosis remains a challenge for clinicians. Here, we report a case of pacemaker lead-induced cardiac perforation rapidly diagnosed by a “bow-and-arrow” sign on point-of-care ultrasound (POCUS).
A 74-year-old Chinese woman who had undergone permanent pacemaker implantation 26 d before suddenly developed severe dyspnea, chest pain, and hypotension. The patient had received emergency laparotomy for an incarcerated groin hernia and was transferred to the intensive care unit 6 d before. Computed tomography was not available due to unstable hemodynamic status, so POCUS was performed at the bedside and revealed severe pericardial effusion and cardiac tamponade. Subsequent pericardiocentesis yielded a large volume of bloody pericardial fluid. Further POCUS by an ultrasonographist revealed a unique “bow-and-arrow” sign indicating right ventricular (RV) apex perforation by the pacemaker lead, which facilitated the rapid diagnosis of lead perforation. Given the persistent drainage of pericardial bleeding, urgent off-pump open chest surgery was performed to repair the perforation. However, the patient died of shock and multiple organ dysfunction syndrome within 24 h post-surgery. In addition, we also performed a literature review on the sonographic features of RV apex perforation by lead.
POCUS enables the early diagnosis of pacemaker lead perforation at the bedside. A step-wise ultrasonographic approach and the “bow-and-arrow” sign on POCUS are helpful for rapid diagnosis of lead perforation.
Core Tip: Pacemaker lead-induced heart perforation is a rare but life-threatening complication of pacemaker implantation. Further, timely diagnosis remains a challenge for clinicians. Here, we report a novel case of right ventricular apex perforation by pacemaker lead associated with pericardial tamponade, which was rapidly diagnosed by a unique “bow-and-arrow” sign on point-of-care ultrasound (POCUS). We also propose a step-wise diagnostic approach using POCUS to enhance diagnostic speed and accuracy for lead-induced heart perforation. This step-wise ultrasonographic approach and the “bow-and-arrow” sign on POCUS are helpful for rapid diagnosis of lead perforation.