Cough, a rare and not well recognized symptom of lead perforation

Aims: Along with relevant progress in technology, pacemaker implantation is continuously
improving its safety and efficacy in treating patients with bradyarrhythmias.
Despite this, this procedure has several complications, including haematoma, pneumothorax,
lead dislodgement, infection, lead perforation, and tamponade.
Methods and results: A 64-year-old woman underwent loop recorder implantation,
after recurrent loss of consciousness, in order to assess arrhythmic causes of syncope.
Two weeks later, an episode of paroxysmal complete AV block, conditioning a
pause of 3 s, was recorded. Thus, the patient was scheduled for urgent dual-chamber
pacemaker implantation. No complication apparently occurred during the procedure.
An active fixation ventricular lead was positioned in right ventricular septal apex
while passive fixation atrium lead in the right appendage. Soon after implantation
the patient started to suffer by non-productive cough, clearly related to ventricular
stimulation, either in DDD or in VVI pacing modality. During spontaneous ventricular
activation (RBBB) no symptoms occurred. Transthoracic echocardiography, performed
the day after implantation, revealed a small pericardial effusion (diastolic diameter
< 10mm) along the apical segments, near the tip of the right ventricular lead.
Suspicion of right ventricular lead perforation arised. The patient underwent urgent
contrast chest CT confirming pericardial effusion, and showing an intramyocardium
placement of the right ventricular apical lead. No active bleeding in pericardium was
observed. Due to persistence of symptoms, we decided to perform right ventricular
lead repositioning in right middle septum, with pericardiocentesis back-up promptly
available. Post-procedure, palpitation, and cough abruptly disappeared. After 3
months follow-up, no significant symptoms were reported and pericardial effusion
gradually disappeared.
Conclusions: We describe a singular case of cough, as atypical symptom immediately
after pacemaker implantation. Pericardial effusion and contrast-CT showing intramyocardial
position of the tip guided our suspicion to a possible right ventricular
lead microperforation. Although right ventricular lead parameters were completely
normal this findings didn’t exclude RV perforation. The lead perforation is known as
a rare complication of device implantation. Typical symptoms of RV lead perforation
are chest pain and hypotension. The patient described in our case showed a haemodynamically
stable pericardial effusion accompanied by non-productive cough,
clearly time-related to RV stimulation. In literature, there is only another similar
case report. The cough is a rare and not well recognized symptom of lead