American Journal of Medical Case Reports
ISSN (Print): 2374-2151 ISSN (Online): 2374-216X Website: Editor-in-chief: Samy, I. McFarlane
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American Journal of Medical Case Reports. 2020, 8(7), 178-181
DOI: 10.12691/ajmcr-8-7-4
Open AccessCase Report

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. McFarlane1,

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.

Pub. Date: April 14, 2020

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


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.

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

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