The associated with a higher risk of cardiac perforation,

The implantable cardioverter
defibrillator (ICD) is an established secondary prevention management for
individuals who survived cardiac arrest by either ventricular tachycardia (VT)
or ventricular fibrillation (VF). 1 In addition, to primary prevention in
individuals who are at an increased risk of sudden cardiac death. 1



However, there is a considerable risk
of complications that has been identified in previous registries and randomised
controlled trials. The largest registry is the US National Cardiovascular Data
Registry (NCDR) ICD registry included 356515 patients who had initial ICD
implantation was published in 2012. 2

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 The registry complication rate was 3.08% and these
included cardiac arrest, perforation, valve injury, coronary venous dissection,
haemo-thorax, pneumothorax, deep vein thrombosis (DVT), transient ischaemic
attack (TIA), stroke, myocardial infarction, pericardial tamponade,
arterio-venous fistula, drug reaction, conduction block, haematoma, lead
dislodgement, peripheral embolus, superficial phlebitis, peripheral nerve
injury and device-related infection). 2


However, a systematic review of
ICD implantation in almost 6800 patients enrolled in RCTs in recent years,
found an overall complication rate of 9.1%, the majority of which arose from
early complications of access issues or lead displacement (5.2%). 3
This was comparable to the more recently published Danish registry
experience, with the total complication rate was reported as 9.5%. 4



Perioperative complications
include lead dis-lodgement, pneumothorax, infections, and bleeding tend to
occur soon after implant, where lead-related problems can occur at any time
during long-term follow-up. 5 The vast majority of lead dis-lodgements
occur within the first post-operative months. 6 Pocket-related complications
including skin erosion, hematoma and seroma, wound infection, or device
migration usually occur within the first 6 months after implantation. 7 The trans-venous lead systems,
present later with lead fractures and insulation defects that may lead to
inappropriate shocks. 6 Necessity for operative revision is reported in 6% of
patients within 1 year of initial implant and up to 15% during 4 years. 5


lead perforation is a
serious complication of ICD leads, although in many cases
the perforations are asymptomatic. The lead perforation is usually a
delayed complication that occurs after one month of implantation.  Delayed lead perforation includes
migration and perforation, with a complication rate ranging from 0.1 to
0.8% for pacemaker leads and 0.6 to 5.2% for ICD leads. 8 Our case highlights
the role of anticoagulation, which increased the risk of bleeding with
perforation. Hence our patient presented with early perforation complication
with cardiac tamponade.


Small-diameter (?8 Fr),
active-fixation leads were associated with a higher risk of cardiac
perforation, with a rate of 1.6% of patients, and in active-fixation leads in 1.4%.

9 Female sex, age >80 years, lead location, lead stiffness, and calibre
size are risk factors for cardiac lead perforation. 10