Left Ventricular and Lung Perforation Caused by a Pacemaker Lead Requiring Emergency Surgical Repair in a Nonagenarian.

Cardiac perforation is an uncommon but potentially life-threatening complication of permanent pacemaker implantation. Delayed perforation involving extracardiac structures is rare; left ventricular free-wall perforation with pulmonary extension is exceptionally uncommon and may be diagnostically challenging, especially when pericardial effusion is absent. A 91-year-old man residing on a Greek island developed delayed perforation of the presumed interventricular septal/paraseptal course with exit through the left ventricular free wall and extension toward the left lung after dual-chamber pacemaker implantation for symptomatic high-grade atrioventricular conduction disease/bradyarrhythmia. Initial computed tomography demonstrated a small left pneumothorax and localized pulmonary hematoma without pericardial effusion. The patient subsequently deteriorated with severe bradycardia and pacing instability, requiring pharmacologic chronotropic/hemodynamic support and urgent air transfer to a tertiary cardiac surgical center. Emergency surgical repair via full median sternotomy was performed without cardiopulmonary bypass. The ventricular lead was withdrawn under direct vision from the left ventricular free-wall perforation and then transected under controlled traction. The left ventricular perforation was repaired with polypropylene sutures. Temporary epicardial atrial and ventricular pacing wires were placed to ensure reliable postoperative rhythm support and hemodynamic stabilization. After clinical stabilization, a definitive permanent pacemaker was implanted using the retained atrial lead and a newly placed ventricular lead to restore dual-chamber pacing. There were no clinical signs of device-related or systemic infection before reimplantation. Recovery was uneventful, and at three-month follow-up, the patient remained asymptomatic with normal device function. This case aims to improve recognition of delayed pacemaker lead perforation as a potential cause of clinical deterioration, even in the absence of pericardial effusion. It also underscores the importance of surgical treatment and the use of temporary epicardial pacing when the perforating lead involves extracardiac structures. Finally, it highlights the need for early cross-sectional imaging and a multidisciplinary approach to decision-making, particularly in very elderly patients.