Right ventricular lead migration to the abdominal cavity: a case report of an unexpected journey.

Background: Lead perforation, though an uncommon complication of cardiac device implantation, is associated with significant morbidity, especially when leads migrate to extracardiac structures. Lead migration into the abdominal cavity is exceedingly rare, and management in such cases can be complex.

Case summary: We present the case of an 82-year-old woman with known dementia who underwent single-chamber pacemaker implantation for symptomatic Mobitz Type II atrioventricular (AV) block. Two weeks post-implantation, the nursing home staff observed that the patient had bradycardia. Electrocardiogram on hospital admission demonstrated recurrence of Mobitz Type II AV block. Pacing checks confirmed there was no lead sensing. Imaging studies confirmed that the right ventricle lead had perforated the myocardium, passed through the diaphragm, and migrated into the abdominal cavity near the colon. The case was discussed in a multidisciplinary team. The final clinical decision was to extract the displaced lead to avoid the risk of further intra-abdominal organ perforations and the risk of developing pericardial effusion. A new lead was successfully implanted in the septal position, with subsequent follow-up showing stable pacing function. The patient received an extended course of antibiotics and made an uneventful recovery leading up to discharge.

Discussion: This case underscores the importance of prompt recognition and a multidisciplinary approach to managing instances of rare lead migration, particularly in elderly, frail patients. Careful imaging and risk assessment helped guide the decision-making process, balancing the risks of lead extraction against potential complications.