Inadvertent left ventricular pacing through a patent foramen ovale: identification, management and implications for postpacemaker implantation checks

Abstract

A dual chamber permanent pacemaker was implanted into an asymptomatic man with complete (third degree) heart block because of the risk of asystole. The ventricular lead was thought to have been attached to the right ventricular septum; however, it inadvertently passed through a patent foramen ovale into the left ventricle. Although the postprocedure ECG showed right bundle branch block this was thought to be due to the presumed septal positioning of the pacing lead. Lead misplacement was not detected on posterioanterior chest X-ray but was clearly demonstrated by transthoracic echocardiography, and subsequently on lateral chest X-ray. The lead was successfully removed and repositioned correctly at the next available opportunity without complication or sequelae.

A pacemaker lead in the left ventricle: An “unexpected” finding?

“…The postoperative chest radiograph is also a valuable aid for identifying lead malposition [7]: LL projection is the clarifying view. On the LL view the tip of a malpositioned LV lead is characteristically steered toward the spine.…”

Incorrect ventricular lead placement into the systemic right ventricle of a patient with D-transposition of the great vessels after Mustard procedure

“…8,9 To mitigate the risk of thromboembolic events in asymptomatic patients, some recommend lead removal in patients without haemodynamically significant heart disease by lead extraction versus surgical removal, whereas others recommending lifetime anticoagulation with warfarin. 10,11 In this population, there have been reports of some patients with chronically implanted leads being treated with aspirin therapy having no thromboembolic events for over 10 years. 11 This case of ventricular lead misplacement in the systemic right ventricle of a patient with D-transposition of the great arteries and complex pulmonary stenosis after Mustard procedure helps highlight the importance of ensuring the ventricular lead is in proper position in patients with complex cardiac anatomy.…”

Complications of electrotherapy – the dark side of treatment with cardiac implantable electronic devices

“…In cases where this is not possible for whatever reason, chronic anticoagulant therapy should be implemented [ 10 , 14 ]. However, the key to preventing such complications is the early detection of improper locations of the leads by fluoroscopy and ECG tracing during the procedure or classic X-ray picture of the chest and echocardiography after the procedure [ 15 ]. Other possible improper locations include the superior vena cava, inferior vena cava, right ventricle (for the atrial electrode), coronary sinus or pulmonary trunk.…”

“…The effect may, but not necessarily, be a functional disturbance such as an increase in the pacing threshold, lead impedance changes, ineffective pacing, improper pacing for a given lead cavity, or impaired alertness due to low signal voltages [ 16 , 17 ]. Under favorable circumstances, dislodgement may remain asymptomatic or nearly asymptomatic, resulting only in non-optimal sensing or stimulation parameters apart from improper lead location [ 15 ]. An example is the unintentional implantation of the right ventricular lead through the coronary sinus to the venous system of the heart [ 18 ].…”

“…Late perforations are defined as occurring over a month after lead implantation [ 3 , 58 ]. Their actual incidence is difficult to estimate, and ranges from 1% to 14% of all late complications [ 3 , 15 ]. Late perforations are asymptomatic or symptomatic, and often irregularities affect only electrical parameters, although they are often found to be normal despite obvious perforations in imaging studies [ 3 ].…”