Extraction of left ventricular pacing lead inserted via the left subclavian artery

560 A 90‐year‐old woman was admitted to the hospi‐ tal for lead removal. Six weeks before admission, she had been implanted a ventricular pacing sys‐ tem owing to symptomatic, second‐degree atrio‐ ventricular block. The ventricular lead was im‐ planted by the vessel punction. A severe condi‐ tion of the patient during the procedure with re‐ curring asystoles and blood pressure drops was most probably the reason why the puncture of the left subclavian artery and implantation of the lead into the left ventricle was not diagnosed. During postoperative period, normal stimula‐ tion parameters were recorded and right bun‐ dle branch block, typical of the left ventricular pacing (FIGURE 1A), was seen on electrocardiogra‐ phy. On chest X‐ray, the image of the lead pass‐ ing along the left subclavian artery, arch‐like up over the pleural cupula and along the left edge of the vertebral column, was not carefully eval‐ uated (FIGURE 1B). The diagnostic procedures were performed af‐ ter the patient was readmitted to the hospital 2 weeks later owing to pacing failure, even with the maximum amplitude and range of impuls‐ es (8 V/1.5 ms). Transthoracic echocardiogra‐ phy and computed tomography revealed the lead passing through the arteries and aortic valve to the left ventricular apex (FIGURE 1CD). Venogra‐ phy of the left‐side venous confluence showed the left subclavian vein passing below the artery with the lead inside (FIGURE 1E). Once the condition was identified, low‐molec‐ ular‐weight heparin was administered and the pa‐ tient, because of her advanced age, was sched‐ uled for transvascular lead extraction. Two days prior to the procedure, the dual chamber pacing system on the right chest side was implanted. The procedure was performed under general an‐ esthesia, with transesophageal echocardiography showing no thrombi on the lead. The osteotomy of the left clavicle was necessary. The subclavi‐ an artery puncture site was protected by the su‐ ture. The lead was extracted by simple traction. With no complications in the perioperative pe‐ riod, the patient was discharged in good condi‐ tion 3 days later. The malpositioned lead implanted in the left ventricle is a rarely diagnosed complication of per‐ manent pacing.1 It is vital to diagnose this com‐ plication to introduce anticoagulant therapy and thus prevent ischemic cerebral stroke. Common diagnostic methods such as electrocardiogram, X‐ray imaging, and transthoracic echocardiogra‐ phy are sufficient to diagnose lead position. So far, only sporadic cases of lead implantation to the left ventricle by the direct puncture of the subclavian artery or aorta have been described.2‐5 In some of these cases, the lead was left in the left ventricle, which required chronic anticoagulant therapy.2 In CLInICAL ImAGE