Delayed Septal Perforation Presenting as Ischaemic Stroke: A Rare Complication of Left Bundle Branch Pacing

Pacemaker lead septal perforation is an uncommon but potentially serious complication. Early identification remains crucial to prevent potential life-threatening events.

A 30-year-old man was admitted with an acute ischemic stroke. Past medical history included a premature pacemaker implantation because of a paroxysmal atrioventricular block, followed by multiple pacemaker-related failures and complications. Nine months before the present admission, a dual-chamber pacemaker with left bundle branch pacing was implanted. At admission, abnormal findings were noted during cardiac rhythm monitoring, and pacemaker interrogation revealed ventricular capture failure. Two-dimensional echocardiography disclosed a septal perforation, with a striking migration of the ventricular lead into the left ventricle. Given the thromboembolic complication, lead removal was indicated. Interestingly, a new tubular "ghost" image was observed on echocardiography after lead removal, with uncertain implications.

Pacemaker septal perforation is very rare but may entail serious risks. Optimal management remains controversial and depends on associated symptoms and complications.

In patients with progressive pacemaker threshold increase, early imaging is key. Lead septal perforation requires careful evaluation given potential associated complications, including thromboembolic risk.