Computed tomography to assess possible cardiac lead perforation

Background: Chest radiography and echocardiography are standard techniques to evaluate possible extracardiac migration of pacemaker and defibrillator leads, but computed tomography (CT) scanning may be a helpful adjunct. Methods: Chest CT using a 64-detector helical scanner was performed in three cases of lead perforation where standard techniques did not yield a definitive diagnosis. In two patients, a cardiac CT protocol was followed, the primary indication for which was to assess the lead tip location. On one patient, persistent chest pain several days after the implant led to a chest CT to rule out a pulmonary embolism, and the extracardiac lead was found fortuitously. Results: In all cases, CT scan images resulted in a definitive diagnosis of extracardiac migration of pacemaker or defibrillator leads. One patient had an extracardiac atrial lead which was dysfunctional but not associated with symptoms. The risks of repositioning were felt to outweigh potential benefits in this patient with chronic obstructive pulmonary disease, and treatment was conservative. The other two patients had extracardiac ventricular leads and were symptomatic with pleuritic chest pain. These patients were treated by lead revision with no evidence of bleeding into the pericardial space. All patients did well and none have suffered any further complications. Conclusion: CT images aid in the diagnosis of lead perforation when other modalities are nondiagnostic. Recent advances in CT technology have been associated with increased use of this technique for evaluation of chest pain, analysis of which should now include location of intracardiac leads.