Misplacement of pacemaker leads: How to avoid and how to approach?

The use of cardiac implantable electronic devices has increased in recent years due to factors such as a growing population, increased life expectancy, and improved access to healthcare services. In parallel with this trend, complications related to pacemakers have also increased. One of the most important and preventable complications among these is lead misplacement. Misplacement of a permanent pacemaker lead in the LV can lead to a variety of complications, including damage to the heart muscle, arrhythmias, blood clotes and cerebrovascular events. It is recommended to use the fluoroscopic 40° LAO view during implantation. That view clearly defines the interatrial and interventricular septum. Right bundle branch block pattern on ECG is an important clue to suspected misplaced lead. In addition to the postero-anterior (PA) projection of x-ray, the latero-lateral (LL) projection provides a clearer view of lead malposition. In the LL view, the tip of an incorrectly positioned LV lead is characteristically directed toward the spine. If diagnosed soon after implantation, percutaneous lead extraction can reduce the risk of future thromboembolic events without the need for lifelong anticoagulation. It should be noted that in cases with a lead in the LV for a long time, lead removal is not the primary recommendation. Patient-based approach should be fundamental.