A 71-year-old woman visited our hospital on September 2, 2020 due to shortness of breath and palpitation after exercise 1 day ago. The symptoms occurred once only and were inactive on admission. Figure 1 shows the timeline of this case. She was diagnosed with sick sinus syndrome with normal atrioventricular conduction and had a single-chamber AAI pacemaker implanted in 2004. The pacemaker was implanted on the right side because of left-handedness. The battery ran out 10 years later and she was admitted to our hospital in 2014. Similar single-chamber pacemakers were not available and not covered by the patient's medical care program anymore. Moreover, her atrioventricular node function had shown to be slightly reduced with age. Thus, the pacemaker was upgraded to a dual-chamber one back then. The atrial lead was kept, while a new ventricular lead was implanted. The patient did not routinely go to follow-up visits in the following 5 years. A chest X-ray image from December 2019 showed that both leads were intact (Figure 2a). Eight months prior to this admission (January 2020), she fell off from a running bicycle, causing blunt force trauma to her right subclavicular region. She went to a community hospital and underwent a chest X-ray screening. It showed a complete right-ventricular pacemaker lead fracture (Figure 2b). The fractured lead was seen at the level of the right clavicle, while the proximal end of the lead was still attached to the pacemaker. The atrial lead was still intact. The patient was suggested to go to a superior hospital for further evaluation and treatment. However, she refused to do so, thinking that it was unnecessary due to the lack of any specific symptoms back then. She was then discharged and did not have any medical visits or hospitalization until this time. Her comorbidities included stable angina and hypertension.
Physical and laboratory examinations on this admission showed no significant findings. Myocardial enzyme test had negative results. Her electrocardiography (ECG) showed atrial pacemaker rhythm and no specific ST-T changes. Chest X-ray scanning had similar findings as compared with 8 months ago, showing a complete ventricular lead fracture (Figure 2c). The results of chest fluoroscopy confirmed that the free end of the fractured ventricular lead was in a fixed position and did not move with heartbeats or change of body position (Figure 3). The patient then underwent a 24 h Holter monitor to further examine the status of her pacemaker. The results showed satisfying atrial sensing and pacing with an AAI pacing mode. Further examinations including coronary angiography and coronary CT angiography were refused by the patient. After symptomatic treatment and observation, the patient was discharged 7 days after admission. The patient had paid follow-up visits routinely after discharge and there were no symptoms up to her latest visit on January 12, 2021.