CTICasesMultiple Malpositioned Cardiac Resynchronization Therapy Leads, Including Right Ventricular Perforation
Imaging findings
In a patient with a cardiac resynchronization therapy device placed at an outside facility, chest radiographs show four leads, one of which is not connected to the pulse generator. The lead intended for the right atrial appendage instead terminates in the SVC without its expected anterior curve. A second lead crosses the midline in the left brachiocephalic vein but then exits the vein entirely, traversing the mediastinal fat anterior to the aorta rather than remaining intravascular. CT confirms the right ventricular lead has perforated through the apical right ventricle to terminate in the mediastinal fat.
Key takeaways
This case demonstrates a "trifecta" of lead malpositions from a single device placement -- an atrial lead short of its target in the SVC, a second lead that exited the venous system entirely into the mediastinal fat (and was apparently abandoned in place), and right ventricular perforation by the ventricular lead -- and it was ultimately explanted and successfully replaced; recognizing extravascular lead course and perforation requires correlating both frontal and lateral radiographic projections with CT.
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