Available online 2 December 2023

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An elderly man with severe Chronic Obstructive Pulmonary Disease (COPD) and a history of complete heart block with pacemaker placement who was found to have an infection in his atrial pacemaker lead and required device extraction. He had a dual chamber pacemaker in place with leads inserted into the right atrium and right ventricle at the time of device implantation however the ECG obtained showed the presence of R wave in lead V1 and S wave in lead I suggestive of left ventricular pacing. Additional imaging CT scan obtained for confirmation revealed that the patient had an enlarged heart displaced to the left hemithorax secondary to lung hyperinflation. Hyperinflated emphysematous lungs from severe COPD can cause postero-lateral rotation of the heart. If the rotation is significant, an RV paced rhythm can show up as S waves in the lateral leads (I, V5–6) and R waves in the right precordial leads (V1–3). This can be misdiagnosed as an LV paced rhythm.

Section snippetsCase summary

An 82-year-old man with a medical history of severe chronic obstructive pulmonary disease (COPD) on 2 L/min supplemental oxygen, complete heart block, status post permanent pacemaker placement (PPM) two years ago, presented with left lower lobe pneumonia and Enterococcus faecalis bacteremia which was complicated by a 2.0 × 1.8 cm mobile vegetation on pacemaker lead in the right atrium and was transferred to our center for infected pacemaker extraction. He underwent pacemaker interrogation and

Discussion

Answer: Right Ventricle (RV)

This ECG demonstrates sinus rhythm with premature atrial complexes with an average atrial rate of 110 beats per minute (bpm). There is complete heart block with no atrioventricular conducted complexes. There is a dissociated ventricular paced rhythm at 70 bpm. There is right bundle branch block (RBBB) morphology (presence of an R wave in lead V1) and S wave in lead I that could suggest left ventricular (LV) pacing [1]. The initial concern with this finding would be

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Patient consent statement

Informed consent was obtained from the involved patient for the collection of medical images/non-identifying patient information to use in scientific publication.

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CRediT authorship contribution statement

Ahmed Shahab: Writing – original draft, Writing – review & editing. Uzair A. Mahmood: Writing – original draft. Amit Noheria: Conceptualization, Writing – original draft, Writing – review & editing.

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