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\begin{document}

\title{Echocardiographic diagnosis of permanent pacemaker lead malposition in
the left ventricle -- A case study.}



\author[1]{Peter Luke}%
\author[2]{Ewen Shepherd}%
\author[2]{Tim Irvine}%
\author[2]{Rae Duncan}%
\affil[1]{Newcastle University Faculty of Medical Sciences}%
\affil[2]{Newcastle Upon Tyne Hospitals NHS Foundation Trust}%


\vspace{-1em}



  
  \date{June 10, 2024}


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\begin{abstract}
Inadvertent endocardial lead malposition is recognised as a rare
incident which is usually underreported and if recognised during
implantation can be easily corrected. This phenomenon is caused by the
ventricular lead unintentionally crossing a pre-existing patent foremen
ovale, septal defects (atrial or ventricular) or directly from the aorta
via an accidental subclavian puncture resulting in the lead implanting
into the left ventricle. While this is a rare occurrence we report the
incidental finding of pacemaker lead malposition during a routine
follow-up transthoracic echocardiogram and the benefits of three
dimensional transoesophageal echocardiography in this patient prior to
lead extraction.%
\end{abstract}%



\sloppy


Case study:

The case study involves a 73 year-old asymptomatic Caucasian male with a
previous history of aortic root and bioprosthetic aortic valve
replacement (AVR) for a 5.8cm ascending aortic aneurysm in 2018 recently
attended a routine follow-up transthoracic echocardiography (TTE) at
their local hospital. A transvenous dual chamber pacemaker was implanted
following the aortic root and AVR for postsurgical transient atrial
fibrillation with permanent atrioventricular heart block. The TTE showed
a well seated bioprosthetic aortic valve with normal peak and mean
gradients and good biventricular function. However, the TTE also clearly
demonstrated a ventricular pacing lead originating from the superior
aspect of the right atrium, crossing both the atrial septum and mitral
valve embedding into the lateral left ventricular (LV) wall (figure one
).

The patient was transferred to a tertiary centre for a transoesophageal
echocardiogram (TOE) to assess the risk of lead derived intra-cardiac
thrombus and discussion at the multi-disciplinary team meeting for
potential lead extraction. A 12-lead electrocardiogram (figure two ) and
chest x-ray (figure three ) was performed following admission to the
tertiary centre showed underlying atrial fibrillation with a VVI
pacemaker induced right bundle branch block morphology. During the TOE
three-dimensional imaging was obtained which demonstrated the right
ventricular lead crossing the atrial septum through a patent patent
foremen ovale and crossing the anterolateral aspect of the mitral valve
between A1 and P1/2 scallops with mild mitral regurgitation. A small
sessile mass attached to the lead in the left atrium measuring 11 x 5mm
was visualised consistent with thrombus (Figures four - seven ).
Infective endocarditis was initially considered as a differential
diagnosis especially in the context of an AVR but excluded as the
patient did not exhibit any major findings on the Duke criteria such as
positive blood cultures or signs of pyrexia. As the patient was high
risk for systemic emboli, anticoagulation with warfarin (5mg) and
subcutaneous Tinzaparin (16,000 units) was offered and advised that a
repeat TOE was required prior to lead removal in six months.

Discussion:

Suspicion should arise of lead malposition if there is a pacemaker
derived right bundle branch block pattern on a 12-lead electrocardiogram
instead of the typical left bundle branch block
morphology\textsuperscript{1}. Utilisation of the posterolateral and
anterolateral projections can differentiate and provide further evidence
that LV malposition may have occurred. Various reports have recommended
or used TTE as an imaging modality if there is a suspicion of lead
malposition which offers the ability to see the lead using the
parasternal, apical and subcostal views\textsuperscript{2,1}. A single
centre study by Ohlow and colleagues (2016) concluded that 0.34\% of
device implants out of 2579 patients between 2007 and 2012 experienced
lead malposition of which the leading cause was unusual thoracic
anatomy, congenital heart disease and operator
inexperience\textsuperscript{3}. Patients with LV lead malposition are
often asymptomatic until presenting with systemic thromboembolic related
complications such as ischemic stroke\textsuperscript{4}.

The incidence of cerebral embolic events have been reported as high as
37\% in patients with LV lead malposition\textsuperscript{3}. The most
common cause of systemic emboli is thrombus or fibrosis formation on the
lead or at the site of implantation. At present there is no clear
recommendations on management of lead malposition with duration between
implant and discovery of lead malposition often influencing treatment.
Incidental findings of lead malposition are often managed with
anticoagulation and antiplatelet therapy in the first instance with the
consideration of percutaneous or surgical lead extraction if deemed
appropriate\textsuperscript{2,1}. As life-long anticoagulation with
Warfarin with a target international nominal ratio of 2.5 -- 3.5 has
been advised in this population\textsuperscript{5}, some papers have not
supported the use of anticoagulation in isolation due to reports of
patients with lead malposition presenting with an ischemic stroke after
prophylactic anticoagulation\textsuperscript{6,7}. Other serious
complications associated with LV lead malposition include mitral valve
leaflet perforation\textsuperscript{8}, mitral
regurgitation\textsuperscript{7} and
endocarditis\textsuperscript{9}which must be taken into consideration
when discussing the benefits and risks of lead extraction. While lead
repositioning is a potential treatment option, caution must be taken to
ensure percutaneous lead extraction does not displace any material which
has formed on the lead\textsuperscript{10}. One strategy recently
reported by Contractor and colleagues (2019) suggested that deploying an
embolic protection device in the brachiocephalic and left carotid artery
can be used to remove the risk of potential cerebral
embolisation\textsuperscript{11}. It is beneficial that the patient
undergo a TTE and TOE prior to the procedure to identify the presence of
mobile thrombus or fibrous material as seen within our case study which
may increase the risk of embolisation during
extraction\textsuperscript{12}. The addition of three dimensional views
during a standard TOE views (3DTOE) has been recognised as a useful
technique to offer supplementary information of thrombus characteristics
and mobility. The advantage of 3DTOE in addition to the already high
spatial resolution and superior visualisation of cardiac anatomy seen in
standard two-dimensional TOE offers high specificity and sensitivity
when visualising presence of intra-cardiac thrombus including left
atrial thrombi. A recent case-study recognised that the use of 3DTOE was
beneficial when assessing a large LV apical thrombus when magnetic
resonance imaging and computed tomography were not
appropriate\textsuperscript{13}. The ability to use offline
reconstructive techniques assists operators to augment image quality
while visualising any mobile components and its attachments to the
surrounding cardiac structures of a suspected thrombus. Another
advantage of using 3DTOE within this particular case-study was the high
quality images of mitral valve anatomy which offers a better perspective
than 2D imaging including good visualisation and size of all scallops
and mitral valve geometry. The benefits of 3DTOE in this case study was
the ability to observe the exact position of the lead crossing the
mitral valve with the use of the `surgeons view', to see if the position
of the pacing lead was negatively impeding the behaviour and mobility of
the mitral valve leaflets and the thrombus attached to the lead in the
left atrium. While some studies have identified that right ventricular
lead extraction is viable and safe option of lead extraction, only few
publicised cases have demonstrated the safe removal of anomalous rhythm
management leads seen in the LV\textsuperscript{13, 14}. Recommendations
provided by the heart rhythm society in 2009 discussing indications for
lead extraction offered caution when considering LV percutaneous lead
extraction with the heightened risk of thromboembolic stroke. Although,
the review cautioned that surgical removal of anomalous transvenous
leads is a class III indication and could be offered at the same time as
other surgical interventions requiring cardiopulmonary
bypass\textsuperscript{15}. Based upon the results of the TEE our
patient was offered anticoagulation and antiplatelet therapy in the
short-term with the goal of percutaneous lead extraction. A TEE was
repeated after six months of medical therapy which showed no evidence of
a mass and the patient was consented for percutaneous lead extraction
due to the patient's co-morbidities making him high risk for surgery.

\textbf{Conflict of interest:}

None.

References:

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3). Ohlow, A-M, Roos, M, Lauer, B., von Korn, H., \& Geller, J. C.
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