Inadvertent malposition of a permanent pacemaker ventricular lead into the left ventricle which was initially missed and diagnosed two years later: a case report

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Abstract

Introduction

Inadvertent malposition of a pacemaker ventricular lead into the left ventricle is an uncommon event, and its actual incidence is probably unknown. It may be underestimated and underreported because of a possible asymptomatic course. A 12-lead electrocardiogram is important to confirm proper placement.

Case presentation

We report a case of a 60-year-old Caucasian man with a malpositioned transvenous permanent pacing lead into the left ventricle via a patent foramen ovale that was not suspected during implantation and went undiagnosed for two years without complications. The patient remained asymptomatic as he was being treated with oral anticoagulation therapy for atrial fibrillation. The decision was made to leave the pacing lead in place and continue lifelong warfarin therapy.

Conclusions

Inadvertent insertion of pacing wires into the left ventricle is a potentially dangerous complication that may happen under fluoroscopic guidance and may be overlooked by routine pacemaker interrogation. It is advisable to obtain a 12-lead electrocardiogram during or immediately after transvenous pacemaker implantation rather than use a routine pacemaker interrogation or a limited electrocardiogram.

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Most cited references 11

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Diagnosis and management of inadvertently placed pacing and ICD leads in the left ventricle: a multicenter experience and review of the literature.

J. Seger, Frank A. L. E. Bracke, J W BOTMAN … (2000)

Three patients from different centers with pacemaker or ICD leads endocardially implanted in the left ventricle are described. All leads, two ventricular pacing leads and one ICD lead, were inserted through a patent foramen ovale or an atrial septum defect. The diagnosis was made 9 months, 14 months, and 16 years, respectively, after implantation. All patients had right bundle branch block configuration during ventricular pacing. Chest X ray was suggestive of a left-sided positioned lead except in the ICD patient. Diagnosis was confirmed with echocardiography in all patients. One patient with a ventricular pacing lead presented with a transient ischemic attack at 1-month postimplantation. During surgical repair of the atrial septum defect 14 months later, the lead was extracted and thrombus was attached to the lead despite therapy with aspirin. The other patients were asymptomatic without anticoagulation (9 months and 16 years after implant). No thrombus was present on the ICD lead at the time of the cardiac transplantation in one patient. We reviewed 27 patients with permanent leads described in the literature. Ten patients experienced thromboembolic complications, including three of ten patients on antiplatelet therapy. The lead was removed in six patients, anticoagulation with warfarin was effective for secondary prevention in the four remaining patients. In the asymptomatic patients, the lead was removed in five patients. In the remaining patients, 1 patient was on warfarin, 2 were on antiplatelet therapy, and in 3 patients the medication was unknown. After malposition was diagnosed, three additional patients were treated with warfarin. In conclusion, if timely removal of a malpositioned lead in the left ventricle is not preformed, lifelong anticoagulation with warfarin can be recommended as the first choice therapy and lead extraction reserved in case of failure or during concomitant surgery.

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An electrocardiographic algorithm for determining the location of pacemaker electrode in patients with right bundle branch block configuration during permanent ventricular pacing.

Ertan Okmen, Izzet Erdinler, Enis Oguz … (2015)

The expected morphology of right ventricular pacing is a left bundle branch block (LBBB) pattern. However, right bundle branch block (RBBB) can also be seen during permanent right ventricular pacing. The aim of this study was to develop an electrocardiographic algorithm to differentiate this benign condition from septal and free wall perforation with subsequent left ventricular pacing. Three hundred consecutive patients who had permanent ventricular or dual-chamber pacemaker implantation between 1999 and 2000 were screened and 25 patients (8.3%) who exhibited RBBB configuration were included in the study. Echocardiograms and chest radiographs were evaluated in order to identify the pacing lead location in this group. The authors formed a study group with their own 25 patients and 22 cases of RBBB with permanent pacemaker from previous publications (total 47 patients). Frontal axis, QRS morphology in lead V(1), and the precordial transition point, which is defined as the precordial lead where R wave amplitude is equal to S wave amplitude, were examined. Placement of precordial leads V(1) and V(2) 1 interspace lower than the standard location (Klein maneuver) eliminated the RBBB pattern in 12 patients. RBBB pattern with "true right ventricular pacing" was detected in 24 of the 25 patients, and in 11 of the 22 patients reported in the literature (total 35 patients). Right ventricular pacing was correctly identified in 34 of 35 patients with use of criteria including left superior axis deviation, RS or qR morphology in lead V(1), and precordial transition at lead V(3) with a high sensitivity and specificity. A simple surface electrocardiogram can accurately predict the lead location in patients having RBBB morphology with right ventricular pacing.

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EFFECT OF PACEMAKER SITE ON CARDIAC OUTPUT AND VENTRICULAR ACTIVATION IN DOGS WITH COMPLETE HEART BLOCK.

S L JOMAIN, D Klotz, Riane B Hoffman … (1964)

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Author and article information

Journal

Journal ID (nlm-ta): J Med Case Reports

Title: Journal of Medical Case Reports

Publisher: BioMed Central

ISSN (Electronic): 1752-1947

Publication date Collection: 2011

Publication date (Electronic): 9 February 2011

Volume: 5

Page: 54

Affiliations

[1 ]Cardiology Department, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, USA

Article

Publisher ID: 1752-1947-5-54

DOI: 10.1186/1752-1947-5-54

PMC ID: 3046900

PubMed ID: 21306607

SO-VID: 31fe966b-6974-400b-83a9-b1615d2bd588

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Inadvertent malposition of a permanent pacemaker ventricular lead into the left ventricle which was initially missed and diagnosed two years later: a case report

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Abstract

Introduction

Case presentation

Conclusions

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Most cited references 11

Diagnosis and management of inadvertently placed pacing and ICD leads in the left ventricle: a multicenter experience and review of the literature.

An electrocardiographic algorithm for determining the location of pacemaker electrode in patients with right bundle branch block configuration during permanent ventricular pacing.

EFFECT OF PACEMAKER SITE ON CARDIAC OUTPUT AND VENTRICULAR ACTIVATION IN DOGS WITH COMPLETE HEART BLOCK.

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