Bow-and-arrow sign on point-of-care ultrasound for diagnosis of pacemaker lead-induced heart perforation: A case report and literature review

Table 1 Laboratory values prior to and after the onset of heart perforation by lead

Variables	Results (prior to the onset)	Results (after the onset)	Normal range
White blood cells	10.04 × 109/L	25.85 × 109/L	3.5-9.5 × 109/L
Hemoglobin	113 g/L	103 g/L	115-150 g/L
Platelets	123 × 109/L	144 × 109/L	100-300 × 109/L
Alanine aminotransferase	12 IU/L	2840 IU/L	7-40 IU/L
Aspartate aminotransferase	17 IU/L	9650 IU/L	13-35 IU/L
Creatinine	0.67 mg/dL	1.14 mg/dL	0.34-1.02 mg/dL
Prothrombin time	10.8 s	27.2 s	9-14 s
Activated partial thromboplastin time	33.5 s	36.9 s	23-32 s
Myohemoglobin	Not tested	201 ng/mL	25-58 ng/mL
Hypersensitive troponin T	Not tested	46.65 ng/L	< 14 ng/L

Table 2 Cases of right ventricular apex perforation by lead diagnosed using ultrasonography

Ref.	Age (yr)/Sex	Types of perforation	Pericardial effusion	Lead passing through RV wall	Lead tip location	Features on ultrasound
Vasavada et al[22], 2014	58/NM	Chronic	Positive	Positive	Pericardial space	Lead passing through the myocardium like a “spear”
Shen et al[23], 2006	97/Woman	Chronic	Positive	Positive	At the perforation	3-D echo enhancing visualization of the pseudoaneurysm by lead
Stefanidis et al[24], 2009	83/Woman	Subacute	Positive	Positive	Pericardial space	3-D echo confirming the lead perforation
Truscelli et al[25], 2011	68/Man	Acute	Positive	Positive	Pericardial space	Lead protrusion through myocardium of RV
Boxma et al[26], 2017	77/Woman	Subacute	Negative	Positive	Pericardial space	Absence of pericardial effusion
Allouche et al[27], 2021	85/Woman	Subacute	Negative	Positive	Pericardial space	Absence of pericardial effusion
Abdelhafez et al[28], 2018	41/Woman	Acute	Positive	Positive	NM	NM
Ferrero-de-Loma-Osorio et al[29], 2009	27/Woman	Chronic	Positive	Positive	Pericardial space	Lead going in and out of RV with each cardiac movement
Ramirez et al[30], 2007	68/Man	Chronic	Negative	Positive	NM	Absence of pericardial effusion
Addison et al[31], 2015	65/Man	Chronic	Positive	Positive	Pericardial space	NM
Hardzina et al[32], 2014	26/Woman	Chronic	Positive	Positive	Pericardial space	NM
Trehan et al[33], 2005	80/Woman	Acute	Positive	Positive	Pericardial space	NM
Velibey et al[34], 2017	92/Woman	Subacute	Positive	Positive	Pericardial space	NM
Chen and Ho[35], 2022	73/Man	Subacute	Positive	Positive	NM	Discontinuation of RV free wall
Sugano et al[36], 2012	73/Man	Acute	Positive	Positive	Pericardial space	3-D echo confirming the lead perforation
Vandenberk et al[37], 2022	81/Man	Chronic	Positive	Positive	Epicardial fat	Lead projecting in the epicardial fat
Caiati et al[38], 2020	51/Man	Subacute	Positive	Positive	Pericardial space	Showing characteristics of the fixating screw and the electrode
Noguchi et al[39], 2017	62/Woman	Subacute	Positive	Positive	Pericardial space	NM
Nash et al[40], 2014	77/Woman	Acute	Positive	NM	Pericardial space	An echo bright structure within the pericardial effusion
Madanat et al[18], 2022	77/Woman	Chronic	Negative	Positive	Pericardial space	TEE showing the lead perforating through the apex
Velasco et al[41], 2014	90/Man	Chronic	Positive	Positive	Pericardial space	NM
Kourireche et al[42], 2017	47/Woman	Chronic	Positive	Positive	Pericardial space	NM

RV: Right ventricle; NM: Not mentioned; 3-D: Three-dimensional; TEE: Transesophageal echocardiography.