Permanent pacing system malfunction due to hidden adjacent fractures of atrial and ventricular leads

Periods of failure of ventricular pacing and atrial sensing were discovered on Holter recording in a 10-year-old boy 4 years after the implantation of a dual-chamber pacemaker with endocardial bipolar leads brought out through the right atrial wall. The old generator was explanted and the old leads tested. There was considerable atrial oversensing of an electrical artefact. The pacing threshold of ventricular lead was 1.8 V compared with 0.3 V 6 days post implantation. Post-operative lateral chest X-ray disclosed fractures of both atrial and ventricular leads at the approximate site of exit from the right atriotomy. Review of the preoperative lateral film showed that the fractures had been hidden by an ECG electrode.