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

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Pacemaker lead malposition in the left ventricle is rare but critical. This case highlights the importance of fluoroscopic views and echocardiography for accurate diagnosis and prompt correction of misplaced leads.

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Area of Science:

  • Cardiology
  • Medical Imaging
  • Electrophysiology

Background:

  • Sick-sinus syndrome necessitates pacemaker implantation.
  • Pacemaker lead malposition, though uncommon, can lead to misdiagnosis.
  • Prompt identification and correction of lead malposition are crucial for patient outcomes.

Observation:

  • A 68-year-old woman presented with asthenia three months post-pacemaker implantation.
  • Transthoracic echocardiography revealed an unusual linear structure crossing the mitral valve into the left ventricle.
  • Electrocardiogram showed right bundle branch block morphology, and chest X-rays were initially misleading.

Findings:

  • Fluoroscopic left-anterior oblique and lateral views, along with transesophageal echocardiography, confirmed left ventricular lead malposition.
  • The lead traversed a patent foramen ovale, mimicking correct placement on standard views.
  • System revision with lead extraction was successfully performed.

Implications:

  • Emphasizes the critical role of specific fluoroscopic views (left-anterior oblique) and lateral chest X-rays in pacemaker lead placement.
  • Highlights the utility of echocardiography in diagnosing lead malposition when standard imaging is equivocal.
  • Underscores the need for prompt detection and correction of misplaced pacemaker leads to prevent complications.