A Stroke of Bad Luck: Left Ventricular Pacemaker Malposition

Lead wire malposition is thought to be a rare complication of both permanent and temporary pacemaker implantation. The actual incidence and prevalence are unknown because of lack of reporting, which complicates consistency in treatment. Potential safeguards to prevent complications as a result of lead malposition are readily available, effective, and inexpensive, but underused. An 80-year-old white man presented to our institution with right-arm paresthesias and weakness, as well as facial numbness, 4 months after undergoing single-chamber pacemaker placement by an outside hospital because of tachybrady syndrome. Computed tomography scan of the head revealed a recent ischemic stroke. Electrocardiography revealed right bundle-branch block morphology of paced beats. Chest radiography raised the suspicion of lead malposition because of the posterior deflection of the lead wire on the lateral view. Transesophageal echocardiography conclusively demonstrated a pacemaker lead wire that transversed the aortic valve into the left ventricle without the presence of thrombus. The patient underwent successful removal of the device with a transcatheter approach, and a replacement pacemaker was placed for symptomatic bradycardia. It was recently suggested that echocardiography is not able to adequately detect thrombi on lead wires and that all patients with stroke should undergo open heart surgery for device extraction. We think that this does not adequately incorporate the significant comorbidities for some patients in the risk-benefit decision-making processes and that a transcutaneous approach is reasonable for patients without evidence of thrombi who are poor surgical candidates for an open heart procedure. A 12-lead electrocardiogram should be performed on every patient after pacemaker insertion. If right bundle-branch block morphology of paced beats is noted, chest radiography including a lateral view should be ordered. If there is any ambiguity regarding lead placement, echocardiography should be performed for determining lead malposition.