Abstract
Background
Temporary transvenous pacemaker implantation is an important and critical procedure
for emergency physicians. Traditionally, temporary pacemakers are inserted by electrocardiography
(ECG) guidance in the emergency department because fluoroscopy at the bedside in an
unstable patient can be limited by time and equipment availability. However, in the
presence of atrial septal defect, ventricular septal defect, and patent foramen ovale,
the pacemaker lead can be implanted inadvertently into the left ventricle or directly
into the coronary sinus instead of right ventricle. Regular pacemaker rhythm can be
achieved despite inadvertent implantation of the pacemaker lead into the left ventricle,
leading to ignorance of the possibility of lead malposition.
Case Report
A 65-year-old female patient with hemodynamic instability and complete atrioventricular
block underwent temporary pacemaker implantation via right jugular vein with ECG guidance
at the emergency department. Approximately 12 h after implantation, it was noticed
that the ECG revealed right bundle branch block (RBBB)−type paced QRS complexes. Diagnostic
workup revealed that the lead was inadvertently located in the left ventricular apex.
This case illustrates the importance of careful scrutiny of the 12-lead ECG and imaging
clues in identifying lead malposition in the emergency department.
Why Should an Emergency Physician Be Aware of This?
Because inadvertent left ventricle endocardial pacing carries a high risk for systemic
embolization, it is important to determine whether an RBBB pattern induced by ventricular
pacing is the result of a malpositioned lead or uncomplicated transvenous right ventricular
pacing.
Keywords
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Article info
Publication history
Published online: March 06, 2018
Accepted:
January 25,
2018
Received in revised form:
December 22,
2017
Received:
July 30,
2017
Footnotes
Streaming video: Two brief real-time video clips that accompany this article are available in streaming video at www.journals.elsevierhealth.com/periodicals/jem. Click on Video Clip 1 and Video Clip 2.
Identification
Copyright
© 2018 Elsevier Inc. All rights reserved.
