The n e w e ng l a n d j o u r na l of m e dic i n e

Images in Clinical Medicine

Stephanie V. Sherman, M.D., Editor

Pacemaker-Lead Dislodgement
and Cardiac Perforation
A

I aVR V1 V4

II
aVL V5
V2

III aVF V3 V6

II

B C

0 cm

Christina Menexi, M.D.

Essex Cardiothoracic Centre
Essex, United Kingdom

Mohamed ElRefai, M.B., B.Ch.,

Ph.D.
Cambridge University Hospitals NHS 15 cm
Foundation Trust
Cambridge, United Kingdom
mohammedelrefai@gmail.com

A
96-year-old woman presented to the emergency department with a 1-day history of pleu-
ritic chest pain 4 days after a single-chamber transvenous pacemaker had been implanted for complete heart
block. Her blood pressure was 100/60 mm Hg, and her heart rate was 40 beats per minute. An electrocar-
diogram showed complete heart block with an atrial rate of 84 beats per minute, a junctional escape with a right
bundle-branch block and a rate of 42 beats per minute, and pacing spikes without ventricular capture (Panel A,
arrows). A chest radiograph showed the tip of the right ventricular lead positioned over the left mid-hemithorax
(Panel B, anteroposterior view). A computed tomographic scan of the chest showed the pacing lead tip traversing
the right ventricle, ending in the left pleural space (Panel C, arrow; sagittal view), and a moderate pleural effusion
on the left side. There was no pneumothorax or pericardial effusion. A diagnosis of pacemaker-lead dislodgement
with cardiac perforation was made. A patient with pacemaker-lead dislodgement may present with chest pain, dyspnea,
syncope, or symptoms of cardiac tamponade or pneumothorax. A percutaneous lead revision was performed urgently
with a cardiothoracic surgical team available as backup. There were no complications. The patient was discharged
home 3 days after presentation.
DOI: 10.1056/NEJMicm2312569
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