To the Editor— Treatment of asystole caused by vagal nerve stimulator

We appreciate the interesting comments made by Drs Contractor and Cooper. We agree that using fluoroscopy to confirm septal placement of right ventricular pacing leads is notoriously difficult. Placement of pacing leads in the inferoseptal or anteroseptal junction, or the right ventricular free wall, appears to be a mechanism for perforation in many cases. Although a computed tomography scan is helpful, lead imaging artifact can make it difficult to evaluate the exact location of the lead. In our case, at surgery, the lead location was confirmed below the left anterior descending artery (LAD) and exiting from the free wall of the left ventricle. We felt that given the location of the lead perforation and relatively young age of the patient, an open surgical approach would be the safest andmost controlled option. After opening the sternum and visualizing the lead exiting the left ventricle lateral to the LAD we felt our approach was prudent. While a nonoperative approach may have been feasible, the potential for bleeding or injury to the LAD could have resulted in a fatal outcome. Our patient was discharged home with no adverse events on postoperative day 4.