Editorial Type:
Article Category: Research Article
 | 
Online Publication Date: Feb 01, 2018

Malposition of Ventricular Pacing Lead via a Venoarterial Course

MD,
MD, and
MD, FACC
Page Range: 50 – 51
DOI: 10.14503/THIJ-16-5953
Save
Download PDF

A 70-year-old woman, told that her pacemaker lead was lying over her aorta, presented for a second opinion. Four years earlier, after a syncopal spell, she had undergone dual-chamber pacemaker placement. Transthoracic echocardiograms revealed that her ventricular pacemaker lead was in her left ventricle (LV). To determine the course of the ventricular lead, transesophageal echocardiography and computed tomographic angiography of the chest were performed (Fig. 1). The lead originated in the subclavian vein but then entered the left common carotid artery, approximately 3.3 cm from its ostium. The lead then coursed through the transverse aortic arch, proximal ascending aorta, and aortic valve, terminating in the distal lateral wall of the LV. The right atrial lead followed the usual venous course into the right atrium. After hearing the risks and benefits of surgically removing the lead from the left common carotid artery, the patient chose lifelong anticoagulation for stroke prophylaxis.

Fig. 1. A) Transesophageal echocardiogram (long-axis view) shows the ventricular pacing lead (arrow) traveling across the ascending aorta (Ao) and into the left ventricle (LV). B) Computed tomographic angiogram of the chest (coronal reformation) shows the lead entering and passing through the proximal left common carotid artery (arrow), continuing through the transverse aortic arch, and terminating in the lateral wall of the LV.Fig. 1. A) Transesophageal echocardiogram (long-axis view) shows the ventricular pacing lead (arrow) traveling across the ascending aorta (Ao) and into the left ventricle (LV). B) Computed tomographic angiogram of the chest (coronal reformation) shows the lead entering and passing through the proximal left common carotid artery (arrow), continuing through the transverse aortic arch, and terminating in the lateral wall of the LV.Fig. 1. A) Transesophageal echocardiogram (long-axis view) shows the ventricular pacing lead (arrow) traveling across the ascending aorta (Ao) and into the left ventricle (LV). B) Computed tomographic angiogram of the chest (coronal reformation) shows the lead entering and passing through the proximal left common carotid artery (arrow), continuing through the transverse aortic arch, and terminating in the lateral wall of the LV.
Fig. 1 A) Transesophageal echocardiogram (long-axis view) shows the ventricular pacing lead (arrow) traveling across the ascending aorta (Ao) and into the left ventricle (LV). B) Computed tomographic angiogram of the chest (coronal reformation) shows the lead entering and passing through the proximal left common carotid artery (arrow), continuing through the transverse aortic arch, and terminating in the lateral wall of the LV.

Citation: Texas Heart Institute Journal 45, 1; 10.14503/THIJ-16-5953

Comment

Malposition of a ventricular lead in the LV occurs infrequently,1,2 and its prevalence has not been reported. Although the lead in our patient traversed the aortic valve, inadvertent crossing of the interatrial septum has been reported more often.3 Potential complications of lead malposition in the LV include systemic thromboembolism, perforation of the aortic or mitral valve leaflets, arterial thrombosis, and loss of capture.4 If malposition is diagnosed immediately after pacemaker implantation, lead removal may be considered.5 Otherwise, the lead should be left in place and lifelong anticoagulation prescribed to reduce the risk of systemic embolization.4

References

  • 1.

    Aguilar JA
    ,
    SummersonC.
    Transarterial permanent pacing of the left ventricle. An unusual complication. Rev Mex Cardiol2002;13(
    2
    ):56–8.

  • 2.

    Kosmidou I
    ,
    KarmpaliotisD
    ,
    KandzariDE
    ,
    DanD.
    Inadvertent transarterial lead placement in the left ventricle and aortic cusp: percutaneous lead removal with carotid embolic protection and stent graft placement. Indian Pacing Electrophysiol J2012;12(
    6
    ):269–73.

  • 3.

    Van Gelder BM
    ,
    BrackeFA
    ,
    OtoA
    ,
    YildirirA
    ,
    HaasPC
    ,
    SegerJJ
    , et al. Diagnosis and management of inadvertently placed pacing and ICD leads in the left ventricle: a multicenter experience and review of the literature. Pacing Clin Electrophysiol2000;23(
    5
    ):877–83.

  • 4.

    Zaher MF
    ,
    AzabBN
    ,
    BoginMB
    ,
    BekheitSG.
    Inadvertent malposition of a permanent pacemaker ventricular lead into the left ventricle which was initially missed and diagnosed two years later: a case report. J Med Case Rep2011;5:54.

  • 5.

    Mazzetti H
    ,
    DussautA
    ,
    TentoriC
    ,
    DussautE
    ,
    LazzariJO.
    Transarterial permanent pacing of the left ventricle. Pacing Clin Electrophysiol1990;13(
    5
    ):588–92.

  • Download PDF
Fig. 1
Fig. 1

A) Transesophageal echocardiogram (long-axis view) shows the ventricular pacing lead (arrow) traveling across the ascending aorta (Ao) and into the left ventricle (LV). B) Computed tomographic angiogram of the chest (coronal reformation) shows the lead entering and passing through the proximal left common carotid artery (arrow), continuing through the transverse aortic arch, and terminating in the lateral wall of the LV.

Contributor Notes

Section Editor: Raymond F. Stainback, MD, Department of Adult Cardiology, Texas Heart Institute, 6624 Fannin St., Suite 2480, Houston, TX 77030

From: Department of Cardiology, Texas Heart Institute, Houston, Texas 77030

Dr. Andrade is now at Advocate Heart Institute, Oak Lawn, Illinois.

Address for reprints: George A. Younis, MD, 6624 Fannin St., Suite 2420, Houston, TX 77030, E-mail: gyounis@gmail.com