Dense Right-Sided Hemiparesis in a 36-Year-Old Woman
Six months after implantation of a dual-chamber pacemaker at an outside facility for sinus bradycardia, a 38-year-old woman had a cerebrovascular accident that resulted in aphasia and dense right-sided hemiparesis. A transthoracic echocardiogram demonstrated a patent foramen ovale, and she was referred for further evaluation. On review of the echocardiogram, it was determined that the atrial lead traversed the patent foramen and the tip was in the mid-left atrium. After >6 weeks of adequate anticoagulation, the lead was removed, and a new atrial lead was placed in the right atrial appendage.
The posteroanterior (PA) and lateral chest x-rays on the left (Figure 1) show the original position of the atrial lead in the left atrium. The PA and lateral chest x-rays on the right (Figure 2) show the new atrial lead in the right atrium. What is notable is that the PA views do not look very different, which would make it difficult to recognize that the original lead was positioned in the left atrium. However, the lateral film clearly shows the atrial lead coursing posteriorly and thus in the left atrium, compared with the lateral film after replacement of the lead, which shows the correct anterior position of the right atrial lead. Lateral chest x-ray films are important after placement of permanent pacing leads to assure proper lead position.