Case Report
A 53-year-old male with a history of coronary artery disease, hypertension, hyperlipidemia, and sick sinus syndrome (SSS) presented to the emergency room for evaluation of dizziness and diaphoresis.
The patient had a history of pacemaker implantation at 26 years old after a motor vehicle accident presumably secondary to dizziness and SSS. After implantation, the patient was unable to follow-up with a cardiologist or primary care provider for 27 years. He claims this is because he works as a truck driver and never settled in one place. He has no insurance and usually seeks medical advice only when he has an acute illness. He never established care with a primary care provider or a cardiologist.
In the emergency room, a point of care ultrasound revealed normal ejection fraction and wall motion, as well as sinus bradycardia at rest. No images of the ultrasound were recorded, and thus no comment on the position of the pacemaker leads were made. An AP and lateral chest X-ray were also obtained; despite showing the ventricular lead taking a sharp turn and crossing into the left chamber of the heart in the AP view (Figure 1), the lateral view was deceiving and showed the lead in a normal position (Figure 2). No comment of the lead position was made on either radiograph.
A chest CT without contrast clearly showed the right ventricular lead crossing the interatrial septum, crossing the mitral valve, and finally inserting into the left ventricle (Figure 3). Again, these findings were missed by the reading radiologist because the indication of the study was to rule out pneumonia. Thus, no comment on the misplaced ventricular pacemaker lead was stated.
Because of his dizziness and resting sinus bradycardia, pacemaker interrogation was attempted, but unfortunately was unsuccessful due to dead pacemaker battery. Because of his significant orthostatic dizziness and persistent sinus bradycardia in the low 50s bpm at rest, along with suboptimal heart rate response in mild to moderate activities, we discussed with the patient replacing his pacemaker battery and he agreed. No formal exercise stress test was done to document chronotropic incompetence.
Patient underwent a pacemaker generator change and his baseline pacing rate was set at 70 bpm. He was atrial paced most of the time and, per intra-operative testing, both atrial and ventricular leads were electrically intact. Unfortunately, neither the operator nor the pacemaker representative noted that the patten of the ventricular pacing lead during testing had a right bundle branch block pattern.