Diaphragmatic stimulation: a case of atrial lead dislodgement and right atrium perforation

We report a 48 year old male who presented with diaphragmatic stimulation. The biventricular implantable cardioverter and defibrillator (CRT-D) was implanted two weeks before admission and active fixation lead caused perforation of the right atrial wall. Echocardiography did not demonstrate pericardial effusion but Chest X-ray and computed tomography (CT) visualized the atrial screw helix outside the right atrial wall, penetrating through the right lung middle lobe. There was no atrial capture. After changing the pace mode DDDR to VVIR, diaphragmatic stimulation was disappeared. The atrial lead was repositioned and fixed again. During the hospital admission and after that the patient was well and free of any symptoms.