Subacute Apical RV Lead Microperforation in CRT Implantation: An Electrical Diagnosis.

BACKGROUND

Right ventricular (RV) lead perforation is a rare complication of cardiac implantable electronic device implantation and may be difficult to diagnose when imaging findings are absent or subtle.

CASE SUMMARY: A 54-year-old man developed positional diaphragmatic stimulation 3 days after cardiac resynchronization therapy implantation. Device interrogation demonstrated rising RV pacing thresholds, declining lead impedance, and marked disparity between unipolar and bipolar parameters, with loss of unipolar tip capture despite preserved bipolar capture. Transthoracic echocardiography and fluoroscopy showed no lead displacement or pericardial effusion. Based on these electrical findings, RV lead microperforation was suspected. Lead revision resulted in normalization of device parameters and complete symptom resolution.

DISCUSSION: Microperforation may present without radiographic abnormalities, making diagnosis challenging. This case illustrates how configuration-dependent electrical abnormalities can distinguish microperforation from other causes of lead dysfunction and facilitate early intervention.

TAKE-HOME MESSAGE: Careful interpretation of cardiac implantable electronic device electrical parameters, together with clinical assessment, can enable early diagnosis of lead microperforation even when conventional imaging is unrevealing.