Ventricular pacemaker lead in the left hemithorax: Mechanism
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Late-onset migration of pacing leads in the left hemithorax is a rare but potentially life-threatening complication. Radiological examinations are required to detect any involvement of either left ventricle or lung parenchyma, prompting immediate surgical extraction in this setting. Identification of high-risk patients is mandatory to prevent this complex iatrogenic complication.

A 78-year-old woman with nonrevascularizable multivessel coronary artery disease was implanted with a dual-chamber PM for symptomatic sick sinus syndrome at our institution. Briefly, after cephalic vein access, the two active fixation leads were placed at the middle portion of the right interventricular septum and the right atrial appendage, respectively, with excellent pacing parameters and no peri-procedural complications. Pre-discharge transthoracic echocardiogram showed no signs of structural heart disease.

Two months after discharge, the patient referred to the emergency department for syncopal episodes and unrelenting left chest pain. PM interrogation showed loss of ventricular capture and urgent chest X-ray identified the ventricular lead tip at approximately 3.5 cm from the left cardiac margin, abutting the left chest wall. Similar findings were reported on the thoracic computed tomography (CT) scan, which showed the passage of the left ventricular lead from the interventricular septum to the left ventricular free wall, reaching the left pleural cavity but with no clear signs of left hemothorax.

The subsequent patient's management was thoroughly debated. However, after a thorough research of the available literature and given the potentially life-threatening complications due to transvenous lead removal, the patient was moved to the surgical theater for off-pump lead extraction. Surgical extraction was uncomplicated, and the patient was discharged home 7 days after the procedure with an uneventful 6-month follow-up.