Cardiac tamponade as complication of active-fixation atrial lead perforations: Proposed mechanism and management algorithm

Background: Cardiac tamponade is a rare complication after implantation of dual chamber pacemaker or defibrillator systems. Its pathophysiology and optimal management are not currently well established. Methods: Three cases of cardiac tamponade following successful implantation of transvenous dual chamber pacemakers with active-fixation atrial leads were identified. Results: All three patients with post-implant cardiac tamponade were suspected to have the same etiology of bleeding into the pericardial space. This was due to protrusion of the helix of the active-fixation atrial pacing lead through the atrial wall with subsequent abrasion of visceral pericardial layer and bleeding from the atrium through the perforation. In two patients, the perforation sites were visualized and repaired during open thoracotomy in the operating room. The third patient underwent lead repositioning under fluoroscopic guidance in the electrophysiology laboratory. Conclusion: Based on the reviewed cases, we describe the pathophysiology of, and recommend a safe conservative algorithm for, the management of cardiac tamponade after successful transvenous lead implantation. Percutaneous pericardiocentesis with placement of the pericardial drain followed by lead repositioning under fluoroscopic guidance with surgical backup appears to be safe and effective.