Case Report: A sailor's knot in the heart: percutaneous retrieval of a knotted temporary pacing lead

Background Temporary transvenous pacing in patients with permanent atrial fibrillation and significant tricuspid valve disease is technically challenging, especially in the absence of fluoroscopic guidance. Catheter looping and knot formation are rare but potentially hazardous complications. Case summary An 82-year-old woman with permanent atrial fibrillation and severe mitral and tricuspid valve regurgitation presented with complete atrioventricular block and a ventricular escape rhythm at 28 bpm. A temporary transvenous pacing catheter inserted via the right internal jugular vein failed to achieve consistent ventricular capture and became entrapped at 45 cm, forming a knot near the venous introducer. Given the patient's frailty and high surgical risk, a multidisciplinary team opted for a fully percutaneous strategy for removal. After definitive pacemaker implantation, the knotted catheter was successfully retrieved using a stepwise approach: engagement of the loop with a deflectable ablation catheter, externalization through a femoral sheath, and extraction using a 13-F dilator sheath to minimize venous trauma. Discussion This case highlights procedural pitfalls during emergency temporary pacing without fluoroscopy and illustrates a safe, creative percutaneous solution for knot retrieval using tools familiar to electrophysiology and lead extraction operators.