Uncommon Site of Pacemaker Lead Fracture

pacemaker, complication, lead fractureA 76-year-old man presented with recurrent episodes of presyncope since 2 weeks.There was no preceding history of trauma or evidence of infective endocarditis.Patient had a dualchamber pacemaker (DDDR, St. Jude Medical, Sylmar, CA, USA) that had been implanted 4 years earlier for a trifascicular block with intermittent third-degree atrioventricular block.The leads were implanted through the right subclavian access.Safe introducer technique was adopted for intrathoracic cannulation of the subclavian vein. 1 St. Jude 1688T-58 cm TENDRIL SDX right ventricular lead was positioned in the apex after negotiating the tricuspid valve with direct crossing technique.The ventricular lead was not forced against resistance and the passage of lead was atraumatic, without kinking of the introducer.The procedure was uneventful.An electrocardiogram on admission showed evidence of trifascicular block.Fluoroscopy of the chest in anteroposterior (Fig. 1A) and lateral (Fig. 1B) views showed a ventricular lead fracture at its tip.The lead tip had migrated into the pulmonary artery (arrowhead in Fig. 1).The atrial lead was intact.A new ventricular lead was implanted and the patient was discharged uneventfully.Lead fracture is a common complication and occurs in 1-4% of patients with pacemaker.2,3 The most common sites are at fixation points (such as lateral to subclavian venous entry) due to compression between the clavicle and first rib or entrapment in costoclavicular space.2,3 In our patient, the site of lead fracture was unusual.Importantly, the lead fracture resulted in dislodgement of the tip to a remote area.Hence, there is a distinct possibility of overlooking the site of fracture.Lead fracture at the tip is an extremely rare