Cardiac perforation from implantable cardioverter-defibrillator lead placement: Insights from the National Cardiovascular Data Registry

Background-Cardiac perforation is a feared complication of implantable cardioverter-defibrillator (ICD) lead implantation because of the potential for significant morbidity and mortality. Predictors of perforation and the severity of associated adverse events have not been well studied. We sought to identify predictors of cardiac perforation from ICD lead implantation and subsequent outcomes. Methods and Results-We studied 440 251 first-time ICD recipients in the ICD Registry implanted between January 2006 and September 2011. Using hierarchical multivariable logistic regression adjusting for patient, implanting physician, and hospital characteristics, we examined the predictors of perforation and the association of perforation with other major complications, length of stay, and in-hospital mortality. Cardiac perforation occurred in 625 patients (0.14%). After multivariable adjustment, older age, female sex, left bundle branch block, worsened heart failure class, higher left ventricular ejection fraction, and non-single-chamber ICD implant were associated with a greater odds of perforation. Conversely, atrial fibrillation, diabetes mellitus, previous cardiac bypass surgery, and higher implanter procedural volume were associated with a lower odds of perforation (all P<0.05). After adjustment, ICD recipients with perforation had greater odds of other associated major complications (odds ratio, 27.5; 95% confidence interval, 19.9-38.0; P<0.0001), postprocedural hospital stays >3 days (odds ratio, 16.3; 95% confidence interval, 13.7-19.4; P<0.0001), and in-hospital death (odds ratio, 17.7; 95% confidence interval, 12.2-25.6; P<0.0001). Conclusions-In a large population of ICD recipients, specific patient and implanter characteristics predicted cardiac perforation risk. Cardiac perforation was associated with a substantially increased risk of other major complications, prolonged hospital stays, and death.