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Cardiovascular Images
April 29, 2020

A Man in His 80s With Dyspnea and a Malpositioned Pacemaker Lead

Author Affiliations
  • 1Department of Cardiovascular Sciences, University of Leicester, Leicester, England
  • 2Cardiology Department, Glenfield Hospital, Leicester, England
JAMA Cardiol. 2020;5(6):725. doi:10.1001/jamacardio.2020.0647

A man in his 80s with a decade-old pacemaker, atrial fibrillation, and previous transient ischemic attacks underwent a transthoracic echocardiogram for mild dyspnea. A pacing lead was seen entering the left ventricle. An urgent transesophageal echocardiogram confirmed a lead entering the left atrium via the right upper pulmonary vein through a large sinus venosus atrial septal defect with a dilated right heart and substantial left-to-right shunt (Qp: Qs = 3.7) (Figure). There was also a patent foramen ovale and a partial cortriatriatum dexter. Retrospective review of previous computed tomography results and a postimplant suboptimal transthoracic echocardiogram confirmed the lead position. Because of the patient’s age, minimal symptoms, longevity of the lead, and anticoagulation for atrial fibrillation, a clinical decision was made against surgical atrial septal defect closure or lead extraction. Malposition of pacing lead is a rare complication and can occur through interatrial/ventricular shunts or transarterial access.1,2 This case is unusual because of the advanced age at diagnosis of not 1 but 3 congenital cardiac anomalies.

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