Implantable Cardioverter-Defibrillator (ICD) Lead-Induced Septal and Left Ventricular Perforation in Hypertrophic Cardiomyopathy: A Case Report

TL;DR

A rare case of ICD lead perforation in a patient with hypertrophic cardiomyopathy is reported, emphasizing the importance of early detection and specialized care.

Contribution

This case report highlights a rare complication of ICD implantation in hypertrophic cardiomyopathy involving septal and LV perforation.

Findings

ICD lead perforated the interventricular septum and extended into the left ventricular free wall.

Emergency pericardiocentesis and surgical repair successfully managed the complication.

Hypertrophic myocardium does not prevent ICD lead perforation, requiring individualized management.

Abstract

Left ventricular (LV) perforation caused by an implantable cardioverter-defibrillator (ICD) lead is a rare but potentially fatal complication. We describe the case of a 34-year-old man with hypertrophic cardiomyopathy who underwent single-chamber ICD implantation for primary prevention of sudden cardiac death using an active-fixation transvenous lead positioned in the right ventricular septum. Four days after implantation, he developed acute chest pain, dyspnoea, hypotension, with clinical signs of evolving cardiac tamponade. Transthoracic echocardiography demonstrated a moderate circumferential pericardial effusion, while device interrogation revealed abnormal pacing parameters, prompting emergency pericardiocentesis with immediate haemodynamic stabilization. Computed tomography was subsequently performed to accurately delineate lead position and confirmed perforation through the interventricular septum with extension into the LV free wall, a finding that could not be fully characterized by echocardiography alone. The patient was transferred to a tertiary centre with continuous cardiac surgical support, where lead extraction and surgical repair of the myocardial defects were successfully performed using pledgeted sutures. The postoperative course was uneventful and follow-up imaging confirmed complete resolution of the pericardial effusion. Unlike the typical pattern of right ventricular free-wall perforation, this case involved transseptal migration of an ICD lead with left ventricular involvement, highlighting that hypertrophic myocardium does not preclude this life-threatening complication and underscoring the importance of early recognition and individualized management.

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