PMC9877449_01
Twelve-lead electrocardiogram and coronary angiogram of the patient. (A) The initial electrocardiogram on the admission day showed complete atrioventricular block with frequent premature ventricular contractions. (B) The electrocardiogram immediately after pacemaker (PM) implantation showed the left bundle branch block pattern and the pacing model was VAT. (C) The electrocardiogram on the second post-operative day (POD) showed ventricular pacing failure. (D) The electrocardiogram after transvenous lead extraction and re-fixation showed the right bundle branch block and left axis deviation, and the right ventricular (RV) lead was refixed at the lower RV septum. (E) Hexagonal star symbol shows a diffuse atherosclerotic stenosis was observed in the middle segment of the left anterior descending branch, thus leading to insufficient coronary blood supply on the mid-portion of the interventricular septum. (F) Right coronary artery was relatively normal.
fcvm-09-1089694-g001.jpg
PMC9877449_01_fcvm-09-1089694-g001.jpg
F1
A 92-year-old man was referred to our center for syncope due to a complete atrioventricular block (Figure 1A). Coronary angiography was performed on account of effort angina 3 years ago (Figures 1E, F). Prior coronary angiography revealed a diffuse lesion (percent diameter stenosis 70-80%) in the middle segment of the left anterior descending (LAD) branch (Figure 1E). Electrocardiogram immediately after implantation showed the left bundle branch block pattern (Figure 1B). Electrocardiogram and interrogation showed loss of ventricular capture (Figure 1C). Omega and 1.0 V, respectively) (Figure 1D). On the 10th POD, the patient was discharged, and the subsequent 6 months of follow-up were uneventful.
Various imaging modalities showed the lead perforation. (A) X-ray fluoroscopy image (right anterior oblique 30 ) immediately after implantation showed that the RV lead was placed at the right ventricular (RV) apex. (B) Chest x-ray showed that the RV lead was beyond the left cardiac margin and clearly migrated in the left hemithorax. (C) Thoracic computed tomography (CT) scan showed the RV lead course from the right ventricle (1) to the left cardiac margin (3) in the patient and perforation of the interventricular septum (2) was well-evident. (D) Coronal CT images confirmed the RV lead migration in the left hemithorax. Thoracic CT scan should, therefore, be regarded as the gold standard for the strategical management of this complication.
fcvm-09-1089694-g002.jpg
PMC9877449_01_fcvm-09-1089694-g002.jpg
F2
X-ray fluoroscopy image immediately after implantation showed that the RV lead was fixed properly (Figure 2A). A subsequent immediate chest X-ray identified that the RV lead tip migrated to the region outside the left cardiac margin (Figure 2B). Furthermore, as the thoracic CT scan also showed a small amount of left pleural effusion (Figure 2B) and there were no obvious symptoms of pericardial tamponade (Figures 2C, D), we deduced that the lead had already penetrated the pericardium.
Transvenous lead extraction process. (A) The white arrow shows the lead of the temporary transvenous pacemaker. (B) The white arrow shows the right ventricular (RV) lead was screwed back to the left ventricle. (C) The white arrow shows the RV lead was screwed back to the right ventricle. (D) The white arrow shows the right ventricular lead was refixed at the lower right ventricular septum.
fcvm-09-1089694-g003.jpg
PMC9877449_01_fcvm-09-1089694-g003.jpg
F3
Figures 3A-D depict and describe the entire procedure in detail.