A 79-year-old man presented to his cardiologist with new onset of dizziness and fainting in July 2021. Six months before, the patient had a pacemaker placed in the setting of third-degree atrioventricular block after transcatheter aortic valve replacement with preexisting right bundle branch block. For physiological pacing, LBBAP was established using the stylet-driven, active-helix Biotronik Solia S60 lead delivered via the Biotronik Selectra 3D 55-39 sheath. Implantation was performed as previously described by Huang and colleagues, resulting in stable and good pacing thresholds, pacing impedance, and sensing amplitudes (0.5 V @ 0.4 ms; 351 Omega unipolar, 526 Omega bipolar, 13.5 mV; Figure 1A) after a third positioning attempt. The sheath was carefully peeled after retraction of the stylet, and pacing values remained stable. No special occurrences were noted. The procedure duration was 125 minutes (fluoroscopy time 15.3 minutes, 10 mL contrast dye). Pacemaker interrogation 3 months after implantation revealed constant lead parameters (0.6 V @ 0.4 ms; 351 Omega unipolar, 565 Omega bipolar, 12.8 mV).
At presentation at the cardiologist's office, the electrocardiogram showed an intermittent higher-degree atrioventricular block. Pacemaker interrogation revealed loss of capture and a lead impedance >2000 Omega. At maximum pacing output, intermittent capture was achieved. Chest radiography revealed no obvious lead anomaly or fracture. The patient was promptly admitted for pacing lead revision.
By fluoroscopy, the lead was in place in the ventricular septum, but a possible conductor fracture was visualized by a suggestive lead movement just before the ring electrode at the entry point into the septum (Figure 2A-2C and Supplemental Video). RV capture could be restored by reinserting a stylet in the pacing lead. The lead was subsequently extracted using the inserted stylet, unscrewing, and slight traction. A new LBBAP lead (Biotronik Solia S60) was inserted as described above in a slightly more apical direction with a deeper penetration into the RV septum using a Biotronik Selectra 3D 40-42 sheath, resulting in physiological pacing (Figure 3A and 3B). A detailed investigation of the extracted lead by the manufacturer confirmed the conductor fracture at the described site, possibly provoked mechanically by the septal contractions with every heartbeat. No further damage or lead anomalies were revealed.