Key result
Sheath-delivered LBBAP lead inadvertently traverses an unrecognized sinus venosus defect into the LV.
Why the study?
Inadvertent left ventricular lead placement is a rare complication that exposes patients to systemic thromboembolism.
Case Report (n=1)
Unexplained right-sided dilatation warrants screening for atrial septal defects during pacemaker implantation, as inadvertent direct left ventricular endocardial pacing can mimic expected left bundle branch area pacing electrocardiographic and activation-time criteria.
Answers are grounded in this paper and cite their sources.
Requires caution with conduction system pacing in unexplained right atrial dilation; leaves open the role of routine septal defect screening.
BACKGROUND: Inadvertent left ventricular (LV) lead placement is rare but exposes patients to systemic thromboembolism. CASE SUMMARY: An 89-year-old man received a dual-chamber pacemaker for atrial fibrillation with paroxysmal complete heart block. Severe right atrial dilatation prevented right ventricular lead placement, and the operator converted to a sheath-delivered "left bundle branch area" approach. Seven months later, imaging unexpectedly showed the lead coursing from the superior vena cava through an unrecognized superior sinus venosus defect into the left atrium, across the mitral valve, into the LV. Transesophageal echocardiography confirmed a 30 × 20 mm superior sinus venosus defect with partial anomalous pulmonary venous return. DISCUSSION: A paced right bundle branch block pattern is expected during left bundle branch area pacing, and activation-time criteria may be falsely reassuring when the lead paces the LV endocardium directly. Atrial septal defect screening is warranted whenever right-sided dilatation is unexplained.
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Viscogliosi et al. (2026) conducted a case report in Atrial fibrillation with paroxysmal complete heart block and unrecognized superior sinus venosus atrial septal defect (n=1). Dual-chamber pacemaker via sheath-delivered left bundle branch area pacing approach was evaluated on Inadvertent left ventricular lead placement through an unrecognized superior sinus venosus defect. Sheath-delivered left bundle branch area pacing in an 89-year-old man inadvertently traversed a 30 × 20 mm sinus venosus defect into the left ventricle, identified at 7 months.
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