Delayed Septal Perforation Presenting as Ischaemic Stroke

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BACKGROUND: Pacemaker lead septal perforation is an uncommon but potentially serious complication. Early identification remains crucial to prevent potential life-threatening events. CASE SUMMARY: A 30-year-old man was admitted with an acute ischemic stroke. Past medical history included a premature pacemaker implantation because of a paroxysmal atrioventricular block, followed by multiple pacemaker-related failures and complications. Nine months before the present admission, a dual-chamber pacemaker with left bundle branch pacing was implanted. At admission, abnormal findings were noted during cardiac rhythm monitoring, and pacemaker interrogation revealed ventricular capture failure. Two-dimensional echocardiography disclosed a septal perforation, with a striking migration of the ventricular lead into the left ventricle. Given the thromboembolic complication, lead removal was indicated. Interestingly, a new tubular "ghost" image was observed on echocardiography after lead removal, with uncertain implications. DISCUSSION: Pacemaker septal perforation is very rare but may entail serious risks. Optimal management remains controversial and depends on associated symptoms and complications. TAKE-HOME MESSAGES: In patients with progressive pacemaker threshold increase, early imaging is key. Lead septal perforation requires careful evaluation given potential associated complications, including thromboembolic risk.

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