Fatal case of accidental perforation of ileum by pace wires during coronary bypass grafting

In many centres, epicardal pace wires are routinely implanted during coronary artery bypass surgery to treat postoperative tachy- and brady-arrhythmias. We describe the case of an 88-year-old male, with severe comorbidity, who underwent a successful CABG, but incurred an unacknowledged iatrogenic perforation of the ileum with the placement of an epicardial pace wire. The patient developed septic shock and multi organ failure despite intra-abdominal surgical interventions and intensive care therapy, and died 6 days after CABG.