Abstract
There are some reports of atrial screw-in lead perforation, but the entire lead body is rarely exposed outside the right atrium at an early stage of the procedure. A man in his 80s had undergone catheter ablation for atrial fibrillation (AF) and had recurrent AF and tachycardia-bradycardia syndrome with 8.8 s of sinus arrest, which caused presyncope. The day after the dual-chamber pacemaker was implanted, atrial screw-in lead perforation caused an elevated threshold, a right pneumothorax, bloody pleural effusion, and pneumomediastinum. A small right thoracotomy with thoracoscopy was performed. The lead that completely penetrated the right atrial appendage and was exposed was safely retracted into the heart and removed thoracoscopically. Early surgery is essential when complete lead perforation with elevated threshold is suspected. LEARNING OBJECTIVES: 1.Perforation of the right atrium by the screw-in lead causes contralateral pneumothorax and chest hemorrhage.2.Elevated lead threshold suggests lead perforation outside the myocardium.3.Treatment was possible with a small right thoracotomy combined with thoracoscopy.