Case presentation
An 80-year-old female patient was admitted to our hospital due to dyspnea lasting 3 days. This patient had a dual-chamber pacemaker implantation one month earlier due to sick sinus syndrome with an active fixation lead (Medtronic 5076) in the right atrial appendage and another (Medtronic 5076) in the right ventricular apex. Her vital signs were stable after admission. Echocardiography revealed massive pericardial effusion. Pacemaker programming showed pacing parameters of two leads were both good. Chest X-ray showed that both leads were within cardiac silhouette (Figure 1A). Computed tomographic angiography (CTA) with sagittal multiplanar reconstruction showed the tip of the atrial lead protruded slightly beyond the epicardial fat pad (Figure1B), suggesting a potential atrial lead perforation. Then pericardiocentesis was performed to guard against cardiac tamponade, and hemorrhagic fluid was drained without blood clot, which deepened the suspicion of perforation. Therefore, a small incision operation was performed. During the operation, it was found that the position of the atrial lead was unfixed, and the penetrated part was so short that it appeared as a dot when penetrated, and then disappeared in the surgical field, repeatedly (Figure 1C, D). Afterwards, cardiac was repaired and the criminal lead was embedded. After several days of observation, pericardial effusion disappeared.