The authors describe a case in which a permanent pacing lead was actively fixated into the middle cardiac vein of the coronary sinus — an infrequent but potentially serious complication of permanent pacemaker lead implantation.

Case Report
An 84-year-old male presented with a history of ischemic cardiomyopathy (EF 35%), congestive heart failure (CHF), coronary bypass grafting, and non-sustained VT suppressed by TIKOSYN (Pfizer, New York, NY). The patient had a transvenous internal cardiac defibrillator (ICD) system (EnTrust D154ATG, atrial lead CapSureFix model 5076, right ventricular defibrillation lead Sprint Fidelis 6949; Medtronic, Minneapolis, MN) inserted for primary prevention in March 2006 at another institution, which monitored the patient and device post discharge. Out of concern for diminishing R-waves, a 1388T pace/sense lead (St. Jude Medical, St. Paul, MN) was implanted in the right ventricular apex (RVA).

The patient returned to the hospital several months post discharge with complaints of chest pain on inspiration and increasing shortness of breath. An echo was done, which showed global systolic dysfunction, an ejection fraction of 45% and a moderate pericardial effusion. Subsequently, a pericardiocentesis was performed, 225 ml of bloody fluid was removed, and a Hemovac drain was placed. The patient was discharged a week later.

The patient returned to his local cardiologist and device clinic for ongoing care. In March 2010, the patient presented to the device clinic with complaints of “chest thumping.” The patient was noted to have diaphragmatic stimulation. The right ventricular lead output had adapted to 5.OV at 1.5 ms PW. The lead was reprogrammed to a lesser output with an acceptable safety margin and absence of diaphragmatic stimulation.

During the next several months, the patient complained of increasing fatigue and shortness of breath. He presented to our institution in January 2010 for consideration for cardiac resynchronization therapy. The patient stated he was still actively farming, but an increase in symptoms made it difficult to maintain his workload. Upon evaluation, the patient had an EF of 35%, CHF Class III, native QRS of 178 ms, and was on optimal medication regime for congestive heart failure. The patient paced in the ventricle less than 5%. The patient was explained the benefits and risks of an upgrade to a biventricular ICD, and consented to proceed.