Clinical Communications: Adult| Volume 54, ISSUE 5, e91-e95, May 2018

Inadvertent Left Ventricle Endocardial or Uncomplicated Right Ventricular Pacing: How to Differentiate in the Emergency Department



      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.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Bessman E.S.
        Emergency cardiac pacing.
        in: Roberts J.R. Hedges J.R. Clinical Procedures on Emergency Medicine. 5th edn. Saunders Elsevier, Philadelphia, PA2010: 269-286
        • Van Gelder B.M.
        • Bracke F.A.
        • Oto A.
        • et al.
        Diagnosis and management of inadvertently placed pacing and ICD leads in the left ventricle: a multicenter experience and review of the literature.
        Pacing Clin Electrophysiol. 2000; 23: 877-883
        • Agnelli D.
        • Ferrari A.
        • Saltafossi D.
        • et al.
        A cardiac embolic stroke due to malposition of the pacemaker lead in the left ventricle. A case report.
        Ital Heart J Suppl. 2000; 1: 122-125
        • Reising S.
        • Safford R.
        • Castello R.
        • et al.
        A stroke of bad luck: left ventricular pacemaker malposition.
        J Am Soc Echocardiogr. 2007; 20: 1316
        • Ferri L.A.
        • Farina A.
        • Lenatti L.
        • et al.
        Emergent transvenous cardiac pacing using ultrasound guidance: a prospective study versus the standard fluoroscopy-guided procedure.
        Eur Heart J Acute Cardiovasc Care. 2016; 5: 125-129
        • Mazzetti H.
        • Dussaut A.
        • Tentori C.
        • et al.
        Transarterial permanent pacing of the left ventricle.
        Pacing Clin Electrophysiol. 1990; 13: 588
        • Altun A.
        • Akdemir O.
        • Erdogan O.
        • et al.
        Left ventricular permanent lead insertion through the foramen ovale. A case report.
        Angiology. 2002; 53: 609-611
        • Sharifi M.
        • Sorkin R.
        • Sharifi V.
        • et al.
        Inadvertent malposition of a transvenous-inserted pacing lead in the left ventricular chamber.
        Am J Cardiol. 1995; 76: 92-95
        • Ciolli A.
        • Trambaiolo P.
        • Lo Sardo G.
        • et al.
        Asymptomatic malposition of a pacing lead in the left ventricle: the case of a woman untreated with anticoagulant therapy for eight years.
        Ital Heart J. 2003; 4: 562-564
        • de Cock C.C.
        • van Campen C.M.
        • Kamp O.
        • et al.
        Successful percutaneous extraction of an inadvertently placed left ventricular pacing lead.
        Europace. 2003; 5: 195-197
        • Klein H.O.
        • Beker B.
        • Sareli P.
        • et al.
        Unusual QRS morphology associated with transvenous pacemakers.
        Chest. 1985; 87: 517-521
        • Coman J.A.
        • Trohman R.G.
        Incidence and electrocardiographic localization of safe right bundle branch block configurations during permanent ventricular pacing.
        Am J Cardiol. 1995; 76: 781-784
        • Yang Y.N.
        • Yin W.H.
        • Young M.S.
        Safe right bundle branch block pattern during permanent right ventricular pacing.
        J Electrocardiol. 2003; 36: 67-71
        • Erdogan O.
        • Aksu F.
        Right bundle branch block pattern during right ventricular permanent pacing: is it safe or not?.
        Indian Pacing Electrophysiol J. 2007; 7: 187-191
        • Barold S.S.
        • Narula O.S.
        • Javier R.P.
        • et al.
        Significance of right bundle branch block patterns during pervenous ventricular pacing.
        Br Heart J. 1969; 31: 285-290
        • Mower M.M.
        • Aranaga C.E.
        • Tabatznik B.
        • et al.
        Unusual patterns of conduction produced by pacemaker stimuli.
        Am Heart J. 1967; 74: 24