Fatigue and Syncope Caused by Right Ventricular Perforation by a Pacemaker Lead

Cardiac devices with intra-ventricular leads are associated with a risk of perforation. This can be a diagnostic challenge given that there is a whole spectrum of clinical presentation from incidental discovery on imaging to large effusions and tamponade. Here we present a case where a patient with permanent pacemaker for complete heart block presented with worsening fatigue that deteriorated to syncopal episodes. Electrocardiogram revealed bradycardia with junctional escape and imaging revealed the tip of the right ventricular lead beyond the ventricular wall. The lead was replaced under fluoroscopic guidance without the need for surgical intervention and the patient was ready for discharge on post-procedure day one. Replacement under fluoroscopic guidance is not only safe, but also enables early discharge, which reduces the burden on health care facilities as well as minimizes the patient's number of days lost in the hospital.