LAUSR

A 77-year-old female patient with a history of chronic obstructive pulmonary disease and paroxysmal atrial fibrillation presented to our emergency department with collapse and was diagnosed with sick sinus syndrome. Before pacemaker implantation, echocardiography showed normal dimensions of both atria and ventricles and normal systolic left and right ventricle (RV) function. A DDD-R pacemaker was successfully implanted using active-fixation leads without any acute complications. The day after implantation, sensing and pacing parameters were normal and unchanged. Chest radiography then showed a normal position of both leads (Fig. 1a, b). Subsequently, the patient was discharged the same day in good clinical health. Four days later, however, the patient was readmitted because of sharp chest pain, unrelated to physical activity or posture. Pacemaker data showed a marked switch from bipolar to unipolar lead pacing and malcapture of the RV lead at maximal pacemaker output. Chest radiography revealed an altered RV lead position (Fig. 1c, d). Echocardiography suggested a perforation of the RV lead through the RV apex but without pericardial effusion (Fig. 1e and online video). This raised doubt as to whether the lead tip lay in the pericardial space. Ultimately, thoracic computed tomography (CT) showed that the lead went through the myocardium (Fig. 1f, g). The patient was subsequently transferred to a specialized pacing lead extraction center with surgical backup, where the RV lead was repositioned uneventfully.