cardiac perforation is a dreaded complication of transvenous pacemaker , cardiac resynchronization therapy defibrillator ( crt - d ) , and implantable cardioverter - defibrillator ( icd ) lead placement because of the potential for critical morbidity and mortality .
we report the case of a 45-year - old woman affected by severe dilated cardiomyopathy who was admitted to our cardiology department for an upgrade of a previously implanted pacemaker .
the patient received a vvi pacemaker implant for complete atrioventricular block 22 years earlier and an upgrade ( ddd mode ) 11 years later .
leads were inserted through the left subclavian vein : ( a ) an active fixation double catheter in the right ventricle , ( b ) a bipolar active fixation lead in the right auricle ( fig .
1 ) , and ( c ) a bipolar lead introduced from the coronary sinus into the antero - lateral vein .
the previously implanted pacemaker and one atrial lead were removed ( the old unipolar lead was left in the right ventricle ) and a crt device was connected to the new implanted leads .
after satisfactory r - wave sensing ( > 5  mv ) and pacing thresholds ( < 1.0  v at 0.5-ms pulse width ) had been demonstrated , the patient underwent defibrillation threshold testing ( dft ) to ensure proper device function .
sustained ventricular tachycardia and ventricular fibrillation were induced to make certain that the device was able to constantly sense , detect , and terminate arrhythmias with a shock at 25  j. during skin closure , the patient went into cardiac arrest with pulseless electrical activity .
cardiopulmonary resuscitation maneuvers were performed immediately and echocardiography showed intrapericardial effusion that was partially drained .
after 1  h , pulseless electrical activity persisted , the patient was declared dead , and resuscitation attempts were halted .
the unexpected fatal outcome resulted in an allegation of medical negligence against the operating cardiologists .
a board of physicians consisting of a forensic doctor and a heart surgeon conducted a post - mortem examination and analysis of the medical records . at autopsy
, approximately 180  cm of blood and clots were found inside the pericardial cavity .
careful inspection of the aorta showed a deep lesion , 2  mm in length , on the antero - lateral aspect of the vessel ( fig . 1 ) 2  cm above the valvular plane ( fig .
the lead metal extremity was implanted at the base of the auricle on the medial wall .
the right atrium was very thin , with an average thickness of 2  mm .
histology showed abundant adipose tissue in its context , endocardial fibrosis , and numerous foci of inflammatory infiltration by various elements including lymphocytes and monocytes as well numerous plasma cells and eosinophils , clearly indicating myocarditis that was not recent .
the ascending aorta was incised and approximately 2  cm above the noncoronary cusp , a pinpoint injury related to the lesion described on the aortic adventia ( fig .
the pathogenetic mechanism underlying this patients death can be explained in the following manner : the active lead ( fig .
1 ) , positioned in the right atrium medial aspect , perforated the thin atrial wall and the lateral aspect of the aortic wall .
after aortic perforation , the lead initially remained inside its wall , which explains why the device interrogation revealed satisfactory r - wave sensing ( > 5  mv ) and pacing thresholds ( < 1.0  v at 0.5-ms pulse width ) .
the patient eventually underwent dft to guarantee proper device function . at this point , the active lead , positioned inside the aorta like a cork , slipped out , causing cardiac tamponade . in a review of relevant literature
, we identified only five cases , , , ,   of atrial damage by a pacemaker lead with concomitant aortic wall perforation , as shown in table 1 .
however , not all reports indicate whether the lead responsible for the cardiac laceration was active or passive . a board of physicians conducted a post - mortem examination and their findings did not support a direct allegation of medical negligence against the operating cardiologists who performed the icd implant .
the board analyzed the guidelines for cardiac pacing and cardiac resynchronization therapy and considered the indications for the procedure performed on the patient to be correct .
the increased heart size shifted the right atrial appendage closer to the adjacent lateral aspect of the aorta . at the same time , the remarkable thinness of the right atrium was conducive to wall perforation .
the perforation was not necessarily a result of malpractice in electrode positioning , but was also caused by other factors such as the pressure exerted during cardiac contraction .
moreover , since she was bearing a pacemaker , the patient could not undergo magnetic resonance imaging before the procedure to highlight the thicknesses of the cardiac wall .
in addition , her pre - existing myocarditis undoubtedly reduced the chances of successful resuscitation .
antonino m. grande , affirms on behalf of all co - authors that we have no conflicts of interest in connection with this article .
 a 45-year - old woman with dilated cardiomyopathy was admitted for the upgrade of a previously implanted pacemaker . 
 echocardiography showed intraventricular dyssynchrony and a low ejection fraction ( 0.35 ) . 
 treatment with a cardiac resynchronization therapy defibrillator ( crt - d ) was selected and the device was implanted . 
 crt - d interrogation revealed proper function . 
 following procedure termination , the patient went into cardiac arrest and died despite resuscitation attempts . 
 an autopsy revealed that the medial aspect of the right atrium was pierced by an active lead and that the aorta had a deep lesion , 2  mm in length , on its lateral aspect . 
 we explain the probable pathogenesis of this patients death . 