LEFT-HEART PACING AND CARDIOEMBOLIC STROKE

Three patients with inadvertently positioned left heart pacemaker lead s were admitted for neurological symptoms consistent with embolic stro ke. In one of them, the pacemaker lead crossed the interatrial septum, the mitral valve, and entered the left ventricle. in another it wets erroneously placed through the subclavian artery, across the aortic va lve, and into the left ventricular chamber. In the third patient, the right ventricular lead of a DDD pacemaker was placed in the coronary s inus and the right atrial lead crossed the interatrial septum, and int ermittently entered the left ventricular cavity. Once anticoagulation was initiated, symptoms resolved; they recurred when the level of anti coagulation dropped leading to a major stroke in one of the patients. Two of the patients were on aspirin at the onset of symptoms. We belie ve that every approach must be considered to remove the malpositioned lead. Otherwise, full dose anticoagulation must be initiated since ant iplatelet therapy alone does not confer adequate protection against st roke.