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Ventricular pacing and right bundle branch block morphology: diagnosis and management

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A 28 year old woman had atrioventricular (AV) conduction problems since her childhood and developed a complete AV block with junctional rhythm when she was 15 years old. She became progressively symptomatic from her AV conduction block.

A dual chamber pacemaker was implanted and no symptoms were noted during follow up of several years. This young patient was seen at the pacemaker outpatient clinic four years after the implant. The ECG shows a right bundle branch block pattern, a QRS transition in lead V5, and a frontal axis at +120°. The posterior–anterior (PA)x ray view shows the ventricular lead located at a higher level than usual and without synchronous movement with the tricuspid valve on PA fluoroscopy.

Transoesophageal echocardiography depicted the lead crossing the interatrial septum in the area of the foramen ovale and passing through the mitral valve, with a large thrombus attached to the lead's extremity.

Considering the age of the patient and the presence of a thrombus with potentially disastrous consequences, atriotomy with removal of the left ventricular lead under extracorporeal circulation was decided. Surgery revealed the lead going through a permeable foramen ovale, with a large thrombus attached on the lead at the atrial level and the tip of the lead entrapped in the cordae of the mitral valve. The lead was removed and the foramen closed. A new ventricular lead was inserted in the right ventricle during the same procedure. No further problems occurred during follow up of 18 months.