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Hemoptysis Due to Right Atrial Perforation by an ICD Lead FREE TO VIEW

Natalya Azadeh, MD; Kenneth Sakata, MD; Louis Lanza, MD; Robert Viggiano, MD
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Mayo Clinic, Scottsdale, AZ

Chest. 2014;146(4_MeetingAbstracts):196A. doi:10.1378/chest.1988845
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SESSION TITLE: Miscellaneous Student/Resident Case Report Posters II

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Hemoptysis as a result of cardiac perforation by a pacemaker/implantable cardiac defibrillator (ICD) lead is an exceedingly rare complication. It is even more unusual when it presents without pneumothorax, pericardial effusion or pneumomediastinum.

CASE PRESENTATION: A 74 year old female with non-ischemic cardiomyopathy underwent placement of a dual chamber Medtronic ICD at an outside hospital without early complications. She was incidentally found to have pulmonary nodules (ultimately found to be benign) and referred to Pulmonology for evaluation. History revealed episodes of hemoptysis starting 2 weeks after ICD placement, and review of her chest X-Ray (CXR) showed the atrial lead projecting through the right atrium. Of note there was no pneumothorax or pericardial effusion evident on any imaging modality. Her electrophysiologist opted not to intervene since at that time her symptoms had abated. Unfortunately the hemoptysis recurred and a CXR revealed further migration of the lead into the right middle lobe (Fig 1). She subsequently underwent thoracotomy and successful removal of the atrial ICD lead and repair of the atrial perforation (Fig 2).

DISCUSSION: Hemoptysis as a result of cardiac perforation is an exceedingly rare complication of pacemaker/ICD placement. Whilst atrial lead perforation has been reported previously, usually as a result of venous access during placement [1] ]hemoptysis as a result of lung penetration by an atrial lead, without pericardial effusion, pneumothorax, or pneumomediastinum, has only been noted in 1 other case report.[2] The most common symptoms reported due to cardiac perforation include: chest pain, diaphragm stimulation, hiccough, abdominal pain, and syncope, [3] though often patients are asymptomatic. It is postulated that the low pressure system of the right heart facilitates sealing of the perforation by a combination of muscle contractions and fibrosis[3]. In our case, the lead continued to migrate into the right middle lobe causing recurrent and persistent hemoptysis, which has not been reported previously. In all previous cases of cardiac perforation, lead revision and repositioning was feasible. However in this particular case a dual chamber ICD was deemed unnecessary and the atrial lead was removed without event.

CONCLUSIONS: Hemoptysis caused by ICD/Pacemaker lead perforation of the heart, without pneumothorax or pericardial effusion is extremely rare. The necessity of lead removal is a debated topic and is not always necessary.

Reference #1: García-Anguiano Et al. Hemoptysis, a rare complication of punction-catheterization of the subclavian vein. Rev Clin Esp. 1994;194:202.

Reference #2: Karbasi-Afshar R, Safi M, Serati AR. Diaphragmatic Stimulation: A case of Atrial Lead Dislodgement and Right Atrium perforation. Namazi Cardiology research center, Tehran, Iran.

Reference #3: Marek, B, Janina, S. Right heart perforation by pacemaker leads Intensive Cardiac Therapy Clinic, Institute of Cardiology, Warsaw, Poland

DISCLOSURE: The following authors have nothing to disclose: Natalya Azadeh, Kenneth Sakata, Louis Lanza, Robert Viggiano

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