Cardiac perforation is a rare complication of cardiac implantable electronic device (CIED) implantation but potentially life-threatening. Different clinical presentations are related to the time between implantation and perforation, localization of the perforation, and concomitant lesions in neighboring organs. Diagnosis is based on concomitant analysis of the clinical picture, ECGs, CIED function checkup with a programmer, and review of echocardiographic, X-ray, and computed tomography pictures (Fig. 1).

We retrospectively analyzed data of all patients diagnosed with acute, subacute, or delayed cardiac perforation after permanent CIED implantation from January 2015 to February 2021, in five Tunisian cardiology departments. The clinical characteristics of patients with cardiac perforation including comorbidities clinical signs, device type, the fixation mechanism, location of perforation were described. The result of percutaneous lead extraction or surgical intervention was assessed.

Cardiac perforation was diagnosed in 19 patients: 63% were females. The average age of patients was 72 years old. Almost half (47%) of our patients had type 2 diabetes and 73% had hypertension, but only three patients were treated with antiplatelet therapy and one patient was on anticoagulant treatment. Thirteen patients presented with chest pain and three patients presented with cardiac tamponade. All perforating leads were active fixation leads. The perforation was due to right atrial lead in 2 patients. All the right ventricle (RV) perforating leads were originally placed at the RV apex or anterior wall. Surgical removal of the lead was performed in seven patients while percutaneous lead management was successfully done with 11 patients.

Avoiding unsafe localization of a lead in the apex and free wall of the RV and in the free anterolateral wall of the right atrium, and overscrewing of the lead helix seem to be the best ways of prevention.