Pacemaker lead malposition in various locations has been described in the literature. Lead malposition in left ventricle is a rare and an underdiagnosed complication. We present a 77-year-old man with history of atrial fibrillation and pacemaker placement who was admitted for transient ischemic attack. He was on aspirin, beta blocker, and warfarin with subtherapeutic international normalized ratio. His paced electrocardiogram showed right bundle-branch block, rather than the typical pattern of left bundle-branch block, suggesting pacemaker lead malposition. Further, his chest X-ray and echocardiogram confirmed the pacemaker lead position in the left ventricle instead of right ventricle. He refused surgical removal of the lead and we increased his warfarin dose. Diagnosis of lead malposition in left ventricle, though easy to identify in echocardiogram, requires high index of clinical suspicion. In asymptomatic patients, surgical removal may be deferred for treatment with lifelong anticoagulation. 1. Case Presentation We present a 77-year-old Caucasian man with history of multiple comorbidities including coronary artery disease, diabetes mellitus, atrial fibrillation, pacemaker placement, and 40-pack-years of smoking who presented with complaints of speech disturbance and left-sided numbness and tingling which resolved within couple of hours of the hospitalization. He was diagnosed with transient ischemic attack (TIA). His pacemaker had been implanted for tachy-brady syndrome 36 months prior to this presentation. He was on warfarin, aspirin, and beta blocker for atrial fibrillation. His pulse rate was 105？beats/min, blood pressure 121/51？mmHg, respiratory rate 20/min, and oxygen saturation 96% on 3？L of oxygen. Physical examination revealed irregularly irregular tachycardia, bilateral rhonchi, wheezes, and mild pedal edema. His international normalized ratio (INR) was subtherapeutic at 1.2. Computer tomographic scan of the head was negative for acute process. His electrocardiogram (ECG) showed paced rhythm with right bundle-branch block, rather than the typical pattern of left bundle-branch block (Figure 1). His chest X-ray in lateral projection showed ventricular lead with an abnormal turn (Figure 2). Given the abnormal ECG and chest X-ray findings, pacemaker lead malposition was suspected. Transthoracic echocardiogram confirmed the pacemaker lead position in the left ventricle apex instead of right ventricle, passing through the interatrial septal defect (Figure 3). Cardiac chambers were nondilated with ejection fraction of 65%. There was no associated
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