Malpositioning of a pacemaker lead to the left ventricle accompanied by posterior mitral leaflet injury

Abstract

There have been several reports of a malpositioned pacemaker lead as a complication in pacemaker implantation. Herein we report a rare case of a malpositioned pacemaker lead in the left ventricle, which could occur in patients with cardiac structural abnormalities. A 70-year-old woman, who had undergone implantation of a pacemaker at the left subclavian position for complete atrioventricular block five years previously, was evaluated because of dyspnea and low grade fever. Echocardiography revealed a congenital atrial septal defect through which the lead was placed into the left ventricle. Whereas percuteneous lead removal seemed to be full of risk with concerns of thromboembolic events and infective endocarditis, the patient was referred to our hospital for surgical removal of the wire and closure of the defect. The lead was a screw-in type and removed and was extracted in the theatre using radiography. Intraoperatively it was found that the lead was positioned in the left ventricle apex after perforating the posterior mitral leaflet. Repair of the mitral valve perforation and closure of the septal defect and epicardial pacemaker lead implantation was performed. This case demonstrated the possibility of malposition of the pacemaker lead to the left ventricle in a transvenous pacemaker implantation procedure, which may lead to thromboembolic complication or infective endocarditis, and the pre-eminent role of echocardiography in the diagnosis of cardiac structural abnormalities. A malpositioned pacemaker lead in the left ventricle is a rare complication that can occur in patients with cardiac structural abnormalities. Lateral chest roentgenogram and echocardiography is efficient in preventing this complication. The removal of the lead in concerns of thromboembolic events and infection is preferable.

Double left ventricular pacing following accidental malpositioning of the right ventricular electrode during implantation of a cardiac resynchronization therapy device

“…Electrodes in the arterial circulation without adequate anticoagulation may cause cerebral and systemic embolism [4,7,13] or even left sided endocarditis and valve injury [4,14]. However, incidental diagnosis with asymptomatic course over years of follow-up is common [4,6,7,15].…”

“…However, incidental diagnosis with asymptomatic course over years of follow-up is common [4,6,7,15]. Thrombembolic events may occur in up to 37% of patients [4,5,14]. The management of left ventricular malposition depends on three factors [4,7]: 1. the time from implantation of the misplaced lead, 2. the presence of thrombus on the lead documented by transesophageal echo, 3. the occurence of thrombembolic events.…”

Management of Symptomatic Inadvertently Placed Endocardial Leads in the Left Ventricle

“…The inadvertent placement of cardiac device leads into the LV is a rare but recognized complication that can have severe sequelae 1,2,4 . The overall complication rate for PM placement is 3.4%–5.7% 4 ; however, the incidence of malpositioned PM leads in the LV is unknown.…”

“…Other pathways for PM or ICD lead insertion into the LV have been described in literature; these include congenital or acquired ventricular septal defects and perforations through the interventricular septum or through the aortic valve via the subclavian or axillary artery. Of all of these routes, introduction of the lead via the interatrial septum is the most common pathway described 1 …”

Complications of Pacemaker Implantation

“…The malposition could be discovered years after the implantation and pacing (Vanhercke et al, 2008). There are not recommendations about the removal of lead if there are not concomitant complications such thrombus, embolism or the posterior mitral leaflet perforation causing an acute mitral incompetence (Seki et al, 2009;Van Gelder et al, 2000). In any case, if timely removal of a malpositioned lead in the left ventricle, through a patent foramen ovale or atrial septal defect is not performed, life-long anticoagulation with warfarin should be recommended.…”