Active fixation pacemaker lead perforating cardiac wall.

We present the case of a 90-year-old male patient transferred from another hospital with a diagnosis of pacemaker dysfunction. A permanent pacemaker had been placed one month previously for complete atrioventricular block. At a scheduled checkup with his cardiologist, he reported that he had started experiencing exertional dyspnea and pleuritic pain a few days after discharge. The electrocardiogram showed atrioventricular block with failure of pacemaker capture. The physical exam was unremarkable and he was hemodynamically stable. Suspecting lead malposition or fracture, a chest X-ray and transthoracic echocardiography (Figure 1A) were performed which showed the lead perforating the right ventricle (arrow) and mild cardiac effusion. Computed tomography (CT) (Figure 1B and C) was then performed in order to identify the entire course of the lead. After multidisciplinary discussion involving our surgical and electrophysiological team, it was decided to disconnect the old lead and leave it in place, as the wound was sealed, and to place a new passive fixation electrode (Figure 1D). The patient has been asymptomatic with a good clinical course since the procedure.