Management of an Inadvertently Placed Transarterial Pacemaker Lead in the Left Ventricle: A Step-by-step Approach

Abstract

Inadvertent lead misplacement in the left ventricle can lead to thromboembolic events, valvular damage, and endocarditis. We present a case of an inadvertently placed transarterial pacemaker lead in the left ventricle in a patient who underwent percutaneous lead removal. After a multidisciplinary team discussion involving cardiac electrophysiology and interventional cardiology as well as a discussion of treatment options with the patient, it was decided to proceed with pacemaker lead removal with the Sentinel™ Cerebral Protection System (Boston Scientific, Marlborough, MA, USA) to prevent thromboembolic events. The patient tolerated the procedure well without post-procedural complications and was discharged the next day on oral anticoagulation. We also present a step-by-step approach to perform lead removal with the use of Sentinel™, emphasizing mitigating the stroke and bleeding risks in this patient setting.

Misplacement of pacemaker leads: How to avoid and how to approach?

“…Applying direct pressure to the subclavian artery can be effective, but it may not always be feasible in many situations. In such cases, arterial closure devices or stents graft can be used 3 . However, despite correct venous puncture, the lead crossing from the interatrial septum into the left heart chambers is possible.…”

“…The first of these is chest x‐ray imaging. Standard postero‐anterior (PA) chest x‐ray may not clearly show the malposition because of the left and right ventricles are in the same plane 3 . In addition to the PA projection, the latero‐lateral (LL) projection provides a clearer view of lead malposition.…”

“…In such cases, arterial closure devices or stents graft can be used. 3 However, despite correct venous puncture, the lead crossing from the interatrial septum into the left heart chambers is possible. To confirm this, a perpendicular left anterior oblique view can be performed to verify the position relative to the right ventricle and interatrial septum.…”

“…Standard postero-anterior (PA) chest x-ray may not clearly show the malposition because of the left and right ventricles are in the same plane. 3 In addition to the PA projection, the latero-lateral (LL) projection provides a clearer view of lead malposition. In the LL view, the tip of an incorrectly positioned LV lead is characteristically directed toward the spine.…”