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Visual diagnosis in cardiology: malposition of dual-chamber pacemaker lead.

A 78-year-old woman was seen in our clinics for routine pacemaker follow-up. In 1995 she had received a dual-chamber pacemaker after His bundle ablation for symptomatic drug-refractory atrial fibrillation with consecutive third degree atrioventricular block.

A 12-lead electrocardiograph (Figure 1) showed atrial fibrillation with ventricular pacemaker spikes associated with right bundle-branch block, rather than the typical pattern of left bundle-branch block. A subsequent chest X-ray displayed the atrial lead in proper position and the ventricular lead well within the left ventricular silhouette (Figure 2). Subsequent transthoracic echocardiography demonstrated that the pacemaker lead was crossing the interatrial septum, passing through the mitral valve and entering the lateral left ventricular myocardium. Figure 3 shows a monitor strip during battery exchange with the patient's own rhythm (left axis deviation) followed by VVI stimulation by the newly connected pacemaker, showing an unusual right axis deviation.

This lead malposition was initially detected four years after the implantation in 1999 by a routine chest X-ray for tuberculosis screening. The lead was placed in the left ventricle at that time through a persistent foramen ovale. After detection of the lead malposition the risk of surgical lead extraction was weighed against the possible risk of systemic thromboembolism and the need of long-term anticoagulation. The patient opted against an operative correction and a warfar in sodium therapy was initiated. Since then she has lived without evidence of neurological deficiencies or peripheral embolic phenomena.





(1.) Ciolli A, Trambaiolo P, Lo Sardo G, Sasdelli M, Palamara A. Asymptomatic malposition of a pacing lead in the left ventricle: The case of a woman untrated with antcoagulant therapy for eight years. Ital Heart J 2003; 4:562-564.


Hamm, Germany


Vermont, United States
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Title Annotation:Correspondence
Author:Wedekind, H.; Muller, J.G.
Publication:Anaesthesia and Intensive Care
Article Type:Case study
Geographic Code:1USA
Date:Oct 1, 2007
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