Shift From Left to a Right Bundle Block on ECG Leading to the Diagnosis of a Malpositioned Lead in the Coronary Sinus: A Case Report

Pramod Theetha Kariyanna¹, Yuvraj Singh Chowdhury¹, Amog Jayarangaiah², Jonathan Christopher Francois¹, Pakinam Mekki¹ and Isabel M. McFarlane^1,

¹Division of Cardiovascular Diseases and Department of Internal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, U.S.A.

²Trinity School of Medicine, 925 Woodstock Road, Roswell, GA 30075, U.S.A.

Cite this paper

Pramod Theetha Kariyanna, Yuvraj Singh Chowdhury, Amog Jayarangaiah, Jonathan Christopher Francois, Pakinam Mekki and Isabel M. McFarlane. Shift From Left to a Right Bundle Block on ECG Leading to the Diagnosis of a Malpositioned Lead in the Coronary Sinus: A Case Report. American Journal of Medical Case Reports. 2020; 8(7):178-181. doi: 10.12691/AJMCR-8-7-4

Abstract

On electrocardiography (ECG), ventricular pacing appears as a spikes that precede induced QRS complexes. The induced complexes with a right ventricular lead have the morphology of a left bundle branch block (LBBB). We describe a case of malposition right ventricular (RV) lead in the coronary sinus diagnosed based on the changes noted in the ECG tracing. An 80-year-old man with a pacemaker implanted for high-grade AV block was found unresponsive. Six minutes of cardiopulmonary resuscitation resulted in return of spontaneous circulation. The ECG demonstrated a new paced right bundle branch block (RBBB) pattern. Chest radiography revealed a misplaced right ventricular (RV) lead in the coronary sinus which was confirmed by 2D-echocardiography. The patient’s healthcare proxy (HCP) declined invasive interventions. The patient expired due multiorgan failure secondary to ventilator associated pneumonia. When an RBBB pattern is seen with RV pacing, patients must be evaluated for mispositioning of the RV lead navigation through an atrial septal defect (ASD) or perforation of the ventricular septum, aberrant retrograde conduction, pre-existing right bundle disease and the “pseudo-RBBB” pattern (seen with the ventricular lead placed in the RV apex/distal septum). A frontal axis of 0˚ to 90˚ and precordial transition by lead V3 differentiates RV septal pacing from all forms of LV pacing, including lead placement in the coronary sinus. Our patient had precordial transition at V3.

Keywords

dual-chamber pacemaker, bradyarrhythmia, right lead perforation, right bundle branch pattern, pseudo-RBBB

Copyright

This work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

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