Correspondence

Medical Mystery — The Answer

N Engl J Med 2002; 347:371August 1, 2002

Article

To the Editor:

The medical mystery in the June 13 issue1 involved a 76-year-old man with sinus node disease who was evaluated after an episode of syncope and who received a single-chamber pacemaker through the left subclavian approach. The medial pathway of the pacing lead on the chest film (Figure 1Figure 1Medial Pathway of the Pacing Lead.), coupled with the finding of right bundle-branch block on the paced electrocardiogram (Figure 2Figure 2Electrocardiogram Showing Right Bundle-Branch Block.), confirms that the lead had been passed by means of the subclavian artery through the ascending aorta, across the aortic valve, and into the left ventricle. A new, dual-chamber pacemaker was placed through the right side of the chest, and once stable pacing had been established, the left-sided pacemaker pocket was opened, the generator was removed, and the lead was retracted to the level of the subclavian artery but temporarily left in place to avoid arterial bleeding. The residual fragment of the lead was then removed by a vascular surgeon, who repaired a laceration of the inferior margin of the subclavian artery caused by the original procedure.