Pacing and implantable cardioverter defibrillator lead perforation as assessed by multiplanar reformatted ECG-gated cardiac computed tomography and clinical correlates.

Introduction We aimed to assess the utility of cardiac computed tomography (CT) in the evaluation of right atrial (RA) and right ventricular (RV) pacemaker and implantable cardiac defibrillator lead perforation. Methods Images from a 320-slice electrocardiogram-gated cardiac CT scanner were retrospectively independently analyzed by two reviewers for lead position, pericardial effusion, and perforation. Perforation results were correlated with pacing sensing, impedance, and threshold measurements. Results A total of 52 patients had RV leads and 35 had RA leads. Five of 17 RV apical, one of 35 RV nonapical, and none of the 35 RA leads perforated through the myocardium on CT imaging criteria. Two "clinically" perforated leads (that had protruded 5 mm and 15 mm from the outer edge of the myocardium) had pericardial effusions and changes in pacing parameters, and required RV lead repositioning. In contrast, there were four apparent "radiologic" perforations (that had protruded only an average 1.5 +/- 0.5 mm from the outer edge of the myocardium) that did not require repositioning. These had the radiologic appearance of perforation on cardiac CT; however, they were not associated with pericardial effusions or significant changes in RV pacing lead sensing, impedance, and threshold measurements. Conclusions Cardiac CT scanning with multiplanar reformatting is useful for documenting lead position and assessing for possible cardiac perforation. The clinical significance and natural history of leads with only the appearance of perforation on cardiac CT is uncertain.