Recurrent collapses following permanent pacemaker implantation

Abstract

A 23-year-old lady presented with collapses associated with transient loss of consciousness. She had undergone permanent pacemaker implantation five months earlier for intermittent complete heart block. An echocardiogram showed that the ventricular lead crossed the interatrial septum into left ventricle (LV) (Fig. 1a). Pacing check with a magnet revealed a right bundle branch block (RBBB) pattern indicating that left ventricle was being paced. Lateral chest X-ray (CXR) showed lead malposition (Fig. 1b). Fig. 1 a Transthoracic echocardiogram. 1. PLAX-parasternal long axis, solid arrow-ventricular lead, LA- left atrium, LV- left ventricle, IVS- interventricular septum, RV-right ventricle, MV-mitral valve, AO- aorta. 2. PSAX-parasternal short axis, solid arrow- ... Following the first procedure she only had a postero-anterior CXR showing satisfactory lead position, which alone is inadequate to accurately confirm lead positions. ECG, which could have alerted to the possibility of pacing the LV, was not performed. Lead malposition is a rare complication of pacemaker implantation. Diagnosis of left ventricular lead malposition requires a high index of suspicion. A 12-lead ECG and a lateral CXR following pacemaker implantation can be diagnostic [1]. A 12-lead ECG in pace mode and in case of RBBB pattern echocardiogram for precise lead position has been recommended [2].