S-ICD lead dislodgement in a young isometric athlete: A rare complication.

The subcutaneous implantable cardioverter defibrillator (S-ICD) is an alternative to transvenous ICD in patients who do not need cardiac pacing. We report the case of a young isometric athlete who received S-ICD for primary prevention of sudden death. Lead dislodgement and myopotential noise oversensing during isometric training led to inappropriate shock, and a surgical revision was performed. During the procedure, strong fibrous adhesions were found, requiring polytetrafluoroethylene dilator sheaths. The S-ICD was finally reimplanted. Despite continued isometric training, no more myopotential oversensing occurred after 1-year follow-up. The present case highlights the possible higher risks of lead complication in an isometric athlete and the uncommon effort in removing an old-generation subcutaneous defibrillator lead.

Clinical impact of antithrombotic therapy in transvenous lead extraction complications: a sub-analysis from the ESC-EORP EHRA ELECTRa (European Lead Extraction ConTRolled) Registry.

AIMS: A sub-analysis of the ESC-EHRA European Lead Extraction ConTRolled (ELECTRa) Registry to evaluate the clinical impact of antithrombotic (AT) on transvenous lead extraction (TLE) safety and efficacy. METHODS AND RESULTS: ELECTRa outcomes were compared between patients without AT therapy (No AT Group) and with different pre-operative AT regimens, including antiplatelets (AP), anticoagulants (AC), or both (AP + AC). Out of 3510 pts, 2398 (68%) were under AT pre-operatively. AT patients were older with more comorbidities (P < 0.0001). AT subgroups, defined as AP, AC, or AP + AC, were 1096 (31.2%), 985 (28%), and 317 (9%), respectively. Regarding AP patients, 1413 (40%) were under AP, 1292 (91%) with a single AP, interrupted in 26% about 3.8 ± 3.7 days before TLE. In total, 1302 (37%) patients were under AC, 881 vitamin K antagonist (68%), 221 (17%) direct oral anticoagulants, 155 (12%) low weight molecular heparin, and 45 (3.5%) unfractionated heparin. AC was 'interrupted without bridging' in 696 (54%) and 'interrupted with bridging' in 504 (39%) about 3.3 ± 2.3 days before TLE, and 'continued' in 87 (7%). TLE success rate was high in all subgroups. Only overall in-hospital death (1.4%), but not the procedure-related one, was higher in the AT subgroups (P = 0.0500). Age >65 years and New York Heart Association Class III/IV, but not AT regimens, were independent predictors of death for any cause. Haematomas were more frequent in AT subgroups, especially in AC 'continued' (P = 0.025), whereas pulmonary embolism in the No-AT (P < 0.01). CONCLUSIONS: AT minimization is safe in patients undergoing TLE. AT does not seem to predict death but identifies a subset of fragile patients with a worse in-hospital TLE outcome.

Transvenous lead extraction procedures in women based on ESC-EHRA EORP European Lead Extraction ConTRolled ELECTRa registry: is female sex a predictor of complications?

AIMS: Female sex is considered an independent risk factor of transvenous leads extraction (TLE) procedure. The aim of the study was to evaluate the effectiveness of TLE in women compared with men. METHODS AND RESULTS: A post hoc analysis of risk factors and effectiveness of TLE in women and men included in the ESC-EHRA EORP ELECTRa registry was conducted. The rate of major complications was 1.96% in women vs. 0.71% in men; P = 0.0025. The number of leads was higher in men (mean 1.89 vs. 1.71; P < 0.0001) with higher number of abandoned leads in women (46.04% vs. 34.82%; P < 0.0001). Risk factors of TLE differed between the sexes, of which the major were: signs and symptoms of venous occlusion [odds ratio (OR) 3.730, confidence interval (CI) 1.401-9.934; P = 0.0084], cumulative leads dwell time (OR 1.044, CI 1.024-1.065; P < 0.001), number of generator replacements (OR 1.029, CI 1.005-1.054; P = 0.0184) in females and the number of leads (OR 6.053, CI 2.422-15.129; P = 0.0001), use of powered sheaths (OR 2.742, CI 1.404-5.355; P = 0.0031), and white blood cell count (OR 1.138, CI 1.069-1.212; P < 0.001) in males. Individual radiological and clinical success of TLE was 96.29% and 98.14% in women compared with 98.03% and 99.21% in men (P = 0.0046 and 0.0098). CONCLUSION: The efficacy of TLE was lower in females than males, with a higher rate of periprocedural major complications. The reasons for this difference are probably related to disparities in risk factors in women, including more pronounced leads adherence to the walls of the veins and myocardium. Lead management may be key to the effectiveness of TLE in females.

Combining electromagnetic navigation and 3-D mapping to reduce fluoroscopy time and achieve optimal CRT response.

Implantation of cardiac resynchronization therapy (CRT) devices can be challenging, time consuming, and associated with high-dose x-ray exposure. We present the technique in which an electromagnetic navigation system (MediGuideTM, St. Jude Medical) and an electroanatomical three-dimensional mapping system (EnSite NavX, St Jude Medical) are usefully combined for implanting implantable cardioverter defibrillator CRT devices with strong reduction of x-ray exposure, and for targeting the most delayed regions in the activation maps avoiding scars for optimal CRT response.

The effects of gender on electrical therapies for the heart: procedural considerations, results and complications: A report from the XII Congress of the Italian Association on Arrhythmology and Cardiostimulation (AIAC).

Use of cardiac implantable devices and catheter ablation is steadily increasing in Western countries following the positive results of clinical trials. Despite the advances in scientific knowledge, tools development, and techniques improvement we still have some grey area in the field of electrical therapies for the heart. In particular, several reports highlighted differences both in medical behaviour and procedural outcomes between female and male candidates. Women are referred later for catheter ablation of supraventricular arrhythmias, especially atrial fibrillation, leading to suboptimal results. On the opposite females present greater response to cardiac resynchronization, while the benefit of implantable defibrillator in primary prevention seems to be less pronounced. Differences on aetiology, clinical profile, and development of myocardial scarring are the more plausible causes. This review will discuss all these aspects together with gender-related differences in terms of acute/late complications. We will also provide useful hints on plausible mechanisms and practical procedural aspects.

Lead vegetations in patients with local and systemic cardiac device infections: prevalence, risk factors, and therapeutic effects.

AIMS: Actual rates of lead vegetations (LVs) in cardiovascular device infections (CDI) are debated in this study. The aim of this study is to characterize prevalence and risk factors of LV in patients with CDI treated with lead extraction (LE). METHODS AND RESULTS: Between 2003 and 2011, 293 leads were extracted from 136 patients (age 70.5 ± 14.5 years, 109 male) with infective indications: 39.2% chronic draining sinus, 20.9% pocket infections, and 28.8% systemic infections/sepsis. All patients underwent transesophageal echocardiography (TEE) before LE. Lead vegetation prevalence was 40.4%: 62.2% in systemic infection, but noteworthy in local infection/chronic draining sinus (21.9/36.4%). Younger age, renal disease, ad dialysis were associated with systemic infection. Fever after last intervention, revision, previous reparative procedure, infection at wound/device site and infection >6 months were associated with local infection/chronic draining sinus. Cardiac resynchronization therapy device, fever after last intervention, infection <6 months, renal disease, dialysis, abnormal chest X-ray, fever at admission, pulmonary symptoms, white blood cell (WBC) count, erythrocyte sedimentation rate, C-reactive protein increase and positive blood samples were related to LV. Risk of vegetations was reduced by antibiotic prophylaxis. Multivariate analysis indicated that renal failure and increased WBC count were related to LV. CONCLUSION: Lead vegetations were frequently observed in patients with only local symptoms. Therefore, TEE should be mandatory in all patients undergoing LE for infective indications.

Cardiac Resynchronization Therapy With or Without Defibrillation: A Long-Standing Debate.

Cardiac resynchronization therapy (CRT) was shown to improve cardiac function, reduce heart failure hospitalizations, improve quality of life and prolong survival in patients with severe left ventricular dysfunction and intraventricular conduction disturbances, mainly left bundle branch block, on optimal medical therapy with ACE-inhibitors, ß-blockers and mineralocorticoid receptor antagonists up-titrated to maximum tolerated evidence-based doses. CRT can be achieved by means of pacemaker systems (CRT-P) or devices with defibrillation capabilities (CRT-D). CRT-Ds offer an undoubted advantage in the prevention of arrhythmic death, but such an advantage may be of lesser degree in nonischemic heart failure etiologies. Moreover, the higher CRT-D hardware complexity compared to CRT-P may predispose to device/lead malfunctions and the higher current drainage may cause a shorter battery duration with consequent premature replacements and the well-known incremental complications. In a period of financial constraints, also device costs should be carefully evaluated, with recent reports suggesting that CRT-Ps may be favored over CRT-Ds in patients with nonischemic cardiomyopathy and no prior history of cardiac arrhythmias from a cost-effectiveness point of view. The choice between a CRT-P or a CRT-D device should be patient-tailored whenever straightforward defibrillator indications are not present. The Goldenberg score may facilitate this decision-making process in ambiguous settings. Age, comorbidities, kidney disease, atrial fibrillation, advanced functional class, inappropriate therapy risk, implantable device infections, and malfunctions are factors potentially reducing the expected benefit from defibrillating capabilities. In the future, prospective randomized controlled trials are warranted to directly compare the efficacy and safety of CRT-Ps and CRT-Ds.

Prognostic role of left atrial enlargement in patients with implantable cardioverter defibrillators for primary prevention.

PURPOSE: Left atrial volume index (LAVI) is a predictor of heart failure and adverse events, irrespective of left ventricular systolic function. The role of LAVI in the prediction of appropriate implantable cardioverter-defibrillator (ICD) therapies is currently unclear and was the focus of this study. METHODS: Consecutive heart failure patients with ischaemic (ICM) or idiopathic (DCM) aetiology receiving ICD for primary prevention were included. The primary endpoint was the occurrence of appropriate ICD therapies (ATs): shocks or antitachycardia pacing (ATP). Inappropriate ICD shocks were also assessed as secondary endpoint. RESULTS: Among 198 included patients, severe left atrial dilatation (SLAE = LAVI ≥ 60 ml/m2) was present in 54 (27%). SLAE patients had a higher prevalence of NYHA class ≥ III, severe mitral regurgitation and atrial fibrillation history. During a median follow-up of 45 months (IQR 25-68), ATs occurred more frequently in SLAE group (33% vs. 15%, p = .007) as well as appropriate shocks (24% vs. 10%, p = .014). At multivariate analysis SLAE was an independent predictor of ATs (OR 3.19, 95% CI 1.38-7.38, p = .007). Inappropriate shocks were associated with AF during implantation (p = .03), but not with SLAE (p = .009). CONCLUSION: In DCM or ICM patients candidate to receive an ICD for primary prevention, a severely enlarged left atrium is a predictive factor for ATs (shocks or ATP). The risk of inappropriate shocks was increased in patients with atrial fibrillation, rather than SLAE.

Selective site pacing in paediatric patients: how to recreate a new loop in the right atrium to follow body growth.

In children, intracardiac loops are created to avoid a lead's fracture due to rapid body growth. Selective site pacing needs the insertion of two 4.1 Fr lumenless leads that do not allow direct manoeuvrability and should be extracted when tension on the lead occurs. We describe an easy, safe, and inexpensive technique to reposition the leads and generate new intracardiac loops.

Gram-positive occult bacteremia in patients with pacemaker and mechanical valve prosthesis: a difficult therapeutic challenge.

AIMS: In pacemaker patients with Gram-positive occult bacteremia, it is reasonable to remove the whole stimulation system, but therapeutic decision is sometimes very challenging. METHODS AND RESULTS: A young patient at 6 years of age underwent dual-chamber pacemaker implantation due to complete atrioventricular block after mitral valve replacement. He felt well until November 2008, when he suffered from febrile illness with blood cultures disclosing methicillin-resistant staphylococcus aureus strain. Repeated antibiotic courses were effective only in obtaining temporary remissions. Consecutive transoesophageal echocardiography examinations were inconclusive. A labelled leucocyte scintigraphy, showing increased captation along leads, was very helpful and critical in guiding our decision to extract leads. CONCLUSION: In equivocal cases, or when the hazard of extraction procedure is presumably high, every accessory diagnostic tool (like scintigraphy with labelled leucocytes) is helpful in establishing a definitive diagnosis and in strengthening a somewhat difficult decision.

Ratchet mechanism selectively causing idiopathic macrodislodgement of an active-fixation coronary sinus lead: a case report.

BACKGROUND: 'Idiopathic' lead macrodislodgement may be due to Twiddler's syndrome depending on active twisting of pulse generator within subcutaneous pocket. All leads are involved, at any time from implantation, and frequently damaged. In the past few years, a reel syndrome was also observed: retraction of pacemaker leads into pocket without patient manipulation, owing to lead circling the generator. In other cases, a 'ratchet' mechanism has been postulated. Reel and ratchet mechanisms require loose anchoring, occur generally briefly after implantation, with non-damaged leads. We report the first case of an active-fixation coronary sinus lead selective macrodislodgement involving such ratchet mechanism. CASE SUMMARY: A 65-year-old man underwent biventricular defibrillator device implantation, with active-fixation coronary sinus lead. Eight months later, he complained of muscle contractions over device pocket. At fluoroscopy, coronary sinus lead was found near to pocket, outside of thoracic inlet. Atrial and ventricular leads were in normal position. After opening pocket, a short tract of coronary sinus lead appeared anteriorly dislocated to generator, while greater length of lead body twisted a reel behind. The distal part of lead was found outside venous entry at careful dissection. Atrial and ventricular leads were firmly anchored. DISCUSSION: Our case is a selective 'Idiopathic' lead macrodislodgement, possibly due to a ratchet mechanism between the lead and the suture sleeve, induced by normal arm motion; such mechanism incredibly, and for first time in literature involves a coronary sinus active-fixation lead. CONCLUSION: Careful attention should always be paid to secure anchoring even of active-fixation coronary sinus leads.

Subclinical Left Ventricular Dysfunction in Severe Obesity and Reverse Cardiac Remodeling after Bariatric Surgery.

AIM: Obesity is associated with an increased cardiovascular risk. This study aimed to assess the role of echocardiography in the early detection of subclinical cardiac abnormalities in a cohort of obese patients with a preserved ejection fraction (EF) undergoing bariatric surgery. METHODS AND RESULTS: Forty consecutive severely obese patients (body mass index≥35 kg/m2) referring to our center for bariatric surgery were enrolled in this prospective cohort study. Despite a baseline EF of 61% ± 3%, almost half patients (43%) had a systolic dysfunction (SD) defined as global longitudinal strain (GLS)>-18%, and most of them (60%) had left ventricular hypertrophy (LVH) or concentric remodeling (CR). At 10-months after surgery, body weight decreased from 120 ± 15 kg to 83 ± 12 kg, body mass index from 44 ± 5 kg/m2 to 31 ± 5 kg/m2 (both P < 0.001). Septal and left ventricular posterior wall thickness decreased respectively from 10 ± 1 mm to 9 ± 1 mm (P = 0.004) and from 10 ± 1 mm to 9 ± 1 mm (P = 0.007). All systolic parameters improved: EF from 61% ± 3% to 64% ± 3% (P = 0.002) and GLS from -17% ± 2% to -20% ± 1% (P < 0.001). Epicardial fat thickness reduction (from 4.7 ± 1 mm to 3.5 ± 0.7 mm, P < 0.001) correlated with the reduction of left atrial area (P < 0.001 R = 0.35) and volume (P = 0.02 R = 0.25). Following bariatric surgery, we observed a reduced prevalence of LVH/CR (before 60%, after 22%, P = 0.001) and a complete resolution of preclinical SD (before 43%, after 0%, P < 0.001). Moreover, a postoperative reduction of at least 30 kg correlated with regression of septal hypertrophy (P < 0.001). CONCLUSIONS: Obese patients candidate to bariatric surgery have an high prevalence of preclinical SD and LVH/CR, early detectable with echocardiography. Bariatric surgery is associated with reverse cardiac remodeling; it might also have a preventive effect on atrial fibrillation occurrence by reducing its substrate.

Spot urinary sodium in acute decompensation of advanced heart failure and dilutional hyponatremia: insights from DRAIN trial.

BACKGROUND: Diuretic resistance portends a poor prognosis in acute heart failure, especially in advanced stages. Early identification of a poor response to diuretics may help to improve treatment and outcomes. Spot natriuresis (UNa+) at 2 h from the start of intravenous furosemide has been proposed as an early indicator of diuretic response. Our paper aimed to determine the role of early natriuresis in patients hospitalized with advanced chronic heart failure (ACHF) and high risk of diuretic resistance. METHODS AND RESULTS: We performed a sub-analysis of the DRAIN trial, a randomized clinical trial on 80 patients with acute decompensation of ACHF (NYHA IV, EF ≤ 30%) with low systolic blood pressure (≤ 110 mmHg) and dilutional hyponatremia (sodium ≤ 135 mMol/L) at admission. Patients were divided into two groups according to spot urinary sodium excretion (high: UNa+ > 50 or low: ≤ 50 mEq/L) at 2 h from furosemide administration. Twenty-eight patients (35%) showed a low natriuretic response. As compared to the other patients, this group showed lower daily urinary output (2275 ± 790 vs 3849 ± 2034 mL, p < 0.001), lower body weight reduction after 48 h (1.55 ± - 1.66 vs - 3.55 ± - 2.93 kg, p < 0.001), higher incidence of worsening renal function (32% vs 10%, p 0.02) and increasing rather than reducing NT-proBNP at 72 h (p 0.02). CONCLUSIONS: In patients with ACHF and dilutional hyponatremia, low natriuresis after furosemide is an early marker of poor diuretic response and correlates with higher NT-proBNP and higher incidence of worsening renal function at 72 h.

Correction to: Spot urinary sodium in acute decompensation of advanced heart failure and dilutional hyponatremia: insights from DRAIN trial.

The original version of this article unfortunately contained a mistake.

Diuretic treatment in high-risk acute decompensation of advanced chronic heart failure-bolus intermittent vs. continuous infusion of furosemide: a randomized controlled trial.

BACKGROUND: Diuretic resistance is a common issue in patients with acute decompensation of advanced chronic heart failure (ACHF). The aim of this trial was to compare boluses and continuous infusion of furosemide in a selected population of patients with ACHF and high risk for diuretic resistance. METHODS: In this single-centre, double-blind, double-dummy, randomized trial, we enrolled 80 patients admitted for acute decompensation of ACHF (NYHA IV, EF ≤ 30%) with criteria of high risk for diuretic resistance (SBP ≤ 110 mmHg, wet score ≥ 12/18, and sodium ≤ 135 mMol/L). Patients were assigned in a 1:1 ratio to receive furosemide by bolus every 12 h or by continuous infusion. Diuretic treatment and dummy treatment were prepared by a nurse unassigned to patients' care. The study treatment was continued for up to 72 h. Coprimary endpoints were total urinary output and freedom from congestion at 72 h. RESULTS: 80 patients were enrolled with 40 patients in each treatment arm. Mean daily furosemide was 216 mg in continuous-infusion arm and 195 mg in the bolus intermittent arm. Freedom from congestion (defined as jugular venous pressure of < 8 cm, with no orthopnea and with trace peripheral edema or no edema) occurred more in the continuous infusion than in the bolus arm (48% vs. 25%, p = 0.04), while total urinary output after 72 h was 8612 ± 2984 ml in the bolus arm and 10,020 ± 3032 ml in the continuous arm (p = 0.04). Treatment failure occurred less in the continuous-infusion group (15% vs. 38%, p = 0.02), while there was no significant difference between groups in the incidence of worsening of renal function. CONCLUSION: Among patients with acute decompensation of ACHF and high risk of diuretic resistance, continuous infusion of intravenous furosemide was associated with better decongestion. DRAIN TRIAL: ClinicalTrials.gov number NCT03592836.

Long-term percentage of ventricular pacing in patients requiring pacemaker implantation after transcatheter aortic valve replacement: A multicenter 10-year experience.

BACKGROUND: Recent studies suggest that atrioventricular (AV) conduction may recover after pacemaker (PM) implantation following transcatheter aortic valve replacement (TAVR), but little is known about long-term follow-up of such patients. OBJECTIVE: The purpose of this study was to evaluate the long-term percentage of right ventricular pacing in patients who underwent TAVR and required PM implantation stratified based on the indication for permanent pacing. METHODS: Retrospective analysis of all consecutive patients who underwent TAVR from February 2008 to August 2019 at 3 centers was performed. Patients already implanted with a PM/implantable cardioverter-defibrillator (ICD) before TAVR, implanted with a cardiac resynchronization therapy device, or implanted >30 days after TAVR were excluded. Eligible patients were divided into 2 groups based on the presence (persistent atrioventricular block [AVB] group) or absence (nonpersistent AVB group) of persistent third-degree AVB after TAVR. RESULTS: A total of 1594 patients underwent TAVR. Two hundred four patients were implanted with a PM or ICD after TAVR and 32 met exclusion criteria, so 172 patients were eligible (median time TAVR-PM implant 4 days) for a total of 352 follow-up visits analyzed. A significant difference in the percentage of ventricular pacing was observed at follow-up performed 7-90 days after implantation (98% persistent AVB group vs 8% nonpersistent AVB group; P <.001). This difference remained significant at follow-up performed 91-270 days (95% vs 3.5%; P <.001), 271-540 days (95.5% vs 3%; P = .006), and 541-900 days (97.4% vs 2.2%; P <.001) after implantation. CONCLUSION: Patients requiring PM implantation due to persistent third-degree AVB after TAVR were less likely to show AV conduction recovery, whereas patients implanted for other indications showed a low percentage of pacing during follow-up.

Accuracy of swabs, tissue specimens, and lead samples in diagnosis of cardiac rhythm management device infections.

AIMS: Pacemaker and implantable-cardioverter defibrillator lead infections widely increased with consequent need to accurately recognize responsible bacteria. METHODS: Between May 2003 and December 2007, we extracted 118 leads, 104 (87.3%) due to infections (sepsis, lead-associated endocarditis, pocket infection) or chronic draining sinus (with negative local bacteriological analyses). Swabs and tissue specimens from pocket and fragments of pin and tip of each extracted lead were obtained during extraction and sent for bacteriological examination. RESULTS: Cultures from explanted lead pins returned positive results in 100% of the cases presenting with local infections and in 92.5% of those with chronic draining sinus. In cases of sepsis, positive results of blood samples are less common than lead samples (58.3 vs 86.7, P = 0.02), the latter being more sensitive for infection diagnosis. Concordance between bacterial isolates from pocket and lead is quite low, approaching 45%, seemingly due to contamination effect. Concordance between isolates within the lead (pin and tip) is quite high, close to 70%, reflecting a more accurate expression of the real infection. In cases of sepsis, concordance between lead and blood samples, and mainly from tip and blood, is very high, resembling 80-85%; consequently bacterial isolates from the lead, particularly from lead tip, are clearly associated with clinical infections. CONCLUSIONS: Our results strongly support the hypothesis that chronic draining sinus is often sustained by infection. Moreover, diagnostic accuracy of lead samples is higher not only than swabs and tissue samples, but also than blood samples to confirm an infection and to guide effective therapy.

Occult bacteraemia in cardiac implantable electronic device patients: a review of diagnostic workflow and mandatory therapy.

: Cardiac implantable electronic device (CIED) implantation has greatly increased, with an associated exponential increase in CIED infections (CDIs). Cardiac device related infective endocarditis (CDRIE) has high morbidity and mortality: approximately 10-21%. Therefore, a prompt diagnosis and radical treatment of CDRIE are needed; transvenous lead extraction (TLE) is the mainstay for the complete healing, even if associated with wide logistic problems, high therapeutic costs and high mortality risk for patients. Some criticisms about the value of Duke criteria and their limitations for the diagnosis of CDRIE are known. The significance of classic laboratory data, transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE), considered in the Duke score, are reviewed and critically discussed in this article, with regard to the specific field of the diagnosis of CDI. The need for new techniques for achieving the diagnostic reliability has been well perceived by physicians, and additional techniques have been introduced in the new European Society of Cardiology (ESC) and British Heart Rhythm Society (BHRS) guidelines on infective endocarditis. These suggested techniques, such as 18-Fluorodeoxyglucose PET/computed tomography (FDG-PET/CT), white blood cell PET (WBC PET) and lung multislice CT (MSCT), are also discussed in the study. This short review is intended as an extensive summary of the diagnostic workflow in cases of CDI and will be useful for readers who want to know more about this issue.

A pacemaker lead in the left ventricle: An "unexpected" finding?

Inadvertent malposition of a pacemaker lead in the left ventricle is uncommon, but it should not be misdiagnosed. We report the case of a 68-year-old woman with symptomatic sick-sinus syndrome requiring pacemaker implantation. Shortly afterwards the lead was extracted and a new pacemaker was contralaterally implanted due to pocket hematoma and suspected lead fracture. Three months later, she was referred to our echocardiography laboratory complaining of asthenia. At transthoracic echocardiography an echo-bright linear structure was recognized in left atrium, passing through the mitral valve and leaning against the posterior left ventricular wall. In short-axis and apical views, the lead apparently crossed the interatrial septum through patent foramen ovale. The QRS-paced electrocardiogram showed right bundle branch block morphology. The lead was apparently well positioned, examining the chest X-ray postero-anterior view. On the contrary, by latero-lateral view and left-anterior oblique view, lead curvature was consistent with misplacement into the left ventricle. Malposition was confirmed by transesophageal echocardiography. Given the relatively recent implant, system revision with lead extraction was scheduled and completed without complications. This case report is intended to improve our awareness in the prevention and in the prompt detection of misplaced pacemaker leads in order to manage an immediate correction. .