*2.3.2 Delayed cardiac perforation*

Delayed cardiac perforation secondary to CIED leads is uncommon when compared to acute perforation [60–62]. Patients will typically have symptoms of chest pain and the clinical presentation may not be as dramatic as an acute perforation. Hence a high degree of clinical suspicion needs to be maintained and early imaging including X-ray, echocardiogram, and, if needed, CT scan could be beneficial in these patients [62]. Further, device interrogation may show loss of capture, even at high output. Often these patients may need a multi-disciplinary approach including electrophysiologists and cardiothoracic surgeons [63].
