A case of cardiac tamponade due to coronary artery injury caused by atrial screw-in lead

A 74-year-old man who had a history of paroxysmal atrial fibrillation, visited the emergency department because of syncope. An electrocardiogram showed atrial fibrillation with slow ventricular response and long pauses. A permanent pacemaker was implanted under oral anticoagulation. Two screw-in leads were positioned at the right atrial appendage and the right ventricular apex. Seven hours after the implantation, he collapsed with hypotension due to cardiac tamponade. Vital signs improved after urgent pericardial drainage, but blood was continuously drained from the pericardial catheter. Due to uncontrollable cardiac tamponade, surgical repair was indicated. We found neither of the leads perforated the myocardium, but there was intermittent bleeding from a pin hole injury in the atrial wall site of the right coronary artery. Redness was observed in the right atrial appendage, but there was no bleeding point. We supposed that the screw tip of the atrial lead might have perforated the atrial appendage,　but was retracted spontaneously afterwards. The pin hole was closed with a patch and the postoperative course was uneventful. This is a rare case of cardiac tamponade due to the injury of the coronary artery by a screw-in lead positioned at the right atrial appendage.