This clinical case shows the diagnostic challenge and the management of a 79 y-o male with recent hospitalization for infero-lateral STEMI undergoing primary PCI of Right Coronary Artery with 2 DES and following DDDR MRI PM (pacemaker) implantation due to the development of persistent 2:1 Atrio-Ventricular Block.
One month later, admission at Emergency Department for syncope. Normal parameters were found at laboratory analyses. The electro-stimulator activity evaluation showed a PM malfunction with ventricular capture failure. Thus, the increase of PM output up to electric ventricular capture (8 Volt/120 msec) was performed, but the following Electrocardiogram showed a PM-induced rhythm with RBBB-morphology. Then, the bedside Echocardiogram showed an apparent presence of a linear hyper-echogenic image into left ventricle with no inter-ventricular septal defect neither inter-ventricular shunt, inter-atrial septal hypermobility with no evident inter-atrial shunt at rest; while a chest Radiography identified the atrial and ventricular leads with no accurate individuation of their position.
The patient was admitted in Intensive Cardiac Care Unit with confirmation of intermittent failure to ventricular capture and RBBB-morphology during PM-induced rhythm at telemetry monitoring. Due to Electrocardiographic and Echocardiographic findings, a strong suspect of abnormal position of the ventricular lead into left ventricle through a possible PFO has been raised. A chest Computed Tomography was performed confirming the anomalous position of the ventricular lead: it reached the left atrium through an inter-atrial defect/patent foramen ovale (PFO), then crossing the mitral valve up to left ventricle. The PM-lead repositioning was scheduled two days after. After positioning of temporary stimulator lead in right ventricle, the ventricular lead has been withdrawn from left-side chambers and positioned into septal-apical right ventricle; furthermore, the position of right atrial lead has been optimized (because of frequent spontaneous passage to the left atrium through the PFO, during manual maneuvers) thus obtaining good stability of the device.
During the following days, the telemetry monitoring showed a PM-induced rhythm, without capture nor sensing failure. The chest Radiography confirmed the correct position of leads and the pre-discharge Echocardiography showed a LVEF 57% with no valvular pathology and with atrial and ventricular leads into right-side chambers.