Management of Symptomatic Inadvertently Placed Endocardial Leads in the Left Ventricle

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.

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“…Other complications including severe mitral regurgitation have also been reported 3. Various management strategies have been advocated.…”

Section: Discussionmentioning

confidence: 99%

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

Wynn¹,

Weston

Cooper³

et al. 2013

BMJ Case Reports

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“…Inadvertent placement of a transvenous RV electrode in the left ventricle has been described by several case reports and reviews [4,7]. Electrodes usually reach the left cavity either by direct arterial puncture, via a PFO [3,4,7] or atrial septal defect, or by perforation of the RV wall or interventricular septum [4,5,7,8].…”

Section: Discussionmentioning

confidence: 99%

“…After successful cardiac resynchronization therapy (CRT) procedures, however, combined pacing of RV and LV usually results in a RBBB configuration and a misplaced RV-lead may therefore be missed. To our best knowledge, this problem has not been reported by case reports or recent review articles [4]. …”

Section: Introductionmentioning

confidence: 95%

“…In selected patients difficulties may be caused by congenital variants [1], angiologic abnormalities [2] or misplacement of leads into the arterial circulation [3-6]. In the literature, there are less than 50 case reports describing an incidental malplacement of right ventricular (RV) electrodes into the left ventricle (LV) [4,5]. Usually, the malplacement can be detected by the postprocedure twelve-lead electrocardiogram (ECG) exhibiting an unexpected right bundle branch block (RBBB) pattern instead of the usual left bundle branch (LBBB) appearance [4].…”

Section: Introductionmentioning

confidence: 99%

“…In the literature, there are less than 50 case reports describing an incidental malplacement of right ventricular (RV) electrodes into the left ventricle (LV) [4,5]. Usually, the malplacement can be detected by the postprocedure twelve-lead electrocardiogram (ECG) exhibiting an unexpected right bundle branch block (RBBB) pattern instead of the usual left bundle branch (LBBB) appearance [4]. After successful cardiac resynchronization therapy (CRT) procedures, however, combined pacing of RV and LV usually results in a RBBB configuration and a misplaced RV-lead may therefore be missed.…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

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

Dissmann

Wolthoff

Zabel

2013

J Cardiothorac Surg

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Accidental malpositioning of a right ventricular (RV) electrode has not been previously reported in the context of cardiac resynchronization therapy (CRT).The case of a 75-year old male patient with dilative cardiomyopathy, left ventricular (LV) ejection fraction 23%, New York Heart Association functional heart failure status stage III, left bundle branch block (LBBB) with QRS width of 136 ms, and misplacement of the RV lead to the LV apex during implantation of a CRT defibrillator is described.Following unremarkable implantation, routine interrogation of the CRT device on the first day after the implantation revealed uneventful technical findings. The 12-lead surface electrocardiogram (ECG) showed biventricular stimulation featuring a narrow QRS complex with incomplete right bundle branch block (RBBB) and R>S in V1. The biplane postoperative chest X-ray was graded normal. On routine follow-up one month later, a transthoracic echocardiogram revealed an increased ejection fraction of 51% but the RV lead was placed in the LV apex. An additional transesophageal echocardiogram exhibited an Eustachian valve guiding the lead via the patent foramen ovale through the mitral valve into the LV apex. Operative revision was scheduled and the active fixation lead was uneventful removed from the LV. A new electrode was inserted and placed in the RV apex.Accidental malplacement of the RV electrode to the LV may be difficult to diagnose in the context of CRT patients as a stimulated biventricular ECG with incomplete RBBB appearance is expected in this situation. Careful analysis of lateral radiographic views during the operation is important to ensure correct lead positioning. As timely revision is the preferred procedure, early routine transthoracic echocardiography may be considered for detection of malplacement.

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Percutaneous extraction of inadvertently placed left‐sided pacemaker leads with complete cerebral embolic protection

Bahadorani

Schricker

Pretorius

et al. 2015

Cathet Cardio Intervent

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Lead wire malposition is a known, but rare complication of permanent pacemaker or defibrillator implantation. The actual incidence and prevalence is unknown and management options for inadvertent left ventricular lead malposition have not been uniform. Current recommendations include systemic anticoagulation with warfarin or surgical lead removal with circulatory arrest for compelling clinical scenarios. Percutaneous left-sided lead extraction is contraindicated due to the potentially increased risk of thromboembolic complications associated with this procedure. To our knowledge, this is the first report of percutaneous extraction of inadvertently placed left ventricular and left atrial endocardial pacemaker leads with flow-preserving complete cerebral embolic protection. We also review the current literature regarding the incidence, management, and percutaneous extraction of left-sided cardiac leads.

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Management of Symptomatic Inadvertently Placed Endocardial Leads in the Left Ventricle

Cited by 24 publications

References 11 publications

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

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

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

Percutaneous extraction of inadvertently placed left‐sided pacemaker leads with complete cerebral embolic protection

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