Asymptomatic malposition of pacemaker lead associated with thrombus

Excerpt

Sirs: A 54-year-old female patient, who underwent permanent VDD pacamaker implantation for symptomatic bradycardia 9 years ago at another institution, was admitted to the hospital for pacemaker battery change. Physical examination revealed blood pressure of 110/80 mmHg, heart rate of 50 bpm, respiratory rate of 20 breaths per minute. A grade III/VI pansystolic murmur with maximal intensity was heard at the left sternal border. Electrocardiography showed ventricular pacemaker spikes followed by right bundle branch block pattern. Posterior-anterior chest X-ray suggested atypical lead position. The pacemaker battery was changed successfully and pacemaker functions were normal. Transthoracic echocardiography was done as a routine follow-up before discharge. Transthoracic echocardiography revealed left ventricular hypertrophy, left atrial and right ventricular dilatation, a central type ventricular septal defect with a diameter of 5 mm (maximal gradient = 46 mmHg, Qp/Qs  = 1.3) and a patent foramen ovale with the ventricular lead crossing the defect (Fig. 1). Transesophageal echocardiography revealed a thrombus with a 5 × 6 mm diameter in the interatrial septum (Fig. 2). Coronary angiography revealed normal coronary arteries and Qp/Qs was 1.35. The patient had a history of pacemaker battery change in 2002 and had normal lead functions on routine follow-up.

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