Right coronary artery perforation by an active‐fixation atrial pacing lead resulting in life‐threatening tamponade

Cardiac tamponade resulting from perforation of a cardiac chamber is a relatively rare complication of pacemaker implantation. We report the first case of perforation of the right coronary artery related to the implantation of a screw‐in atrial pacing lead, presenting as life‐threatening cardiac tamponade. We report the case of a 72‐year‐old woman with complete atrioventricular block and dyspnea on exertion. A permanent pacemaker was implanted with bipolar Medtronic active‐fixation leads positioned in the right atrial appendage and at the right ventricular basal septum without any difficulty. Approximately 3.5 h after the procedure, the patient complained of nausea, and the systolic blood pressure decreased to less than 60 mmHg. Echocardiography revealed a large pericardial effusion. Because the effects of pericardiocentesis lasted for less than an hour, the patient underwent a thoracotomy. After evacuation of a massive hemopericardium, bright red blood was seen gushing out from the right coronary artery, which was located on the opposite site of the right atrial appendage where a small portion of the screw tip was observed to be penetrating the atrial wall. The right coronary artery perforation was repaired using autologous pericardium‐reinforced 7–0 prolene mattress sutures. Perforation of the right coronary artery is a potential complication and should be part of the differential diagnosis of cardiac tamponade after pacemaker implantation.