Perforation of the Right Ventricle by Transvenous Defibrillator Leads: Prevention and Treatment

A series of 78 consecutive implants of the transvene PCD (Medtronic, Inc.) defibrillator system is presented and the occurrence of right ventricular perforation in 4 patients reported (5.2%). Diagnosis of perforation is made using four signs: (1) decrease in arterial blood pressure without any other explanation; (2) decrease in pulsatility of the cardiac silhouette as monitored by fluoroscopy; (3) increased size of the cardiac silhouette; and (4) abnormal position of the transvenous lead too far out toward the left ventricle along the pericardial outline. Perforation causes rapid and dramatic cardiac tamponade due to the large diameter and stiffness of the coil carrier lead. Immediate drainage of the hemopericardium must be carried out using the transxiphoid approach. The use of a thin blue-coded lead stylet (0.014-inch gauge) is recommended over the stiffer maroon-coded stylet. Since treatment must be carried out immediately, it is advised that a surgeon either perform, assist, or be immediately available whenever one of these systems is implanted.