Case Report: Double-click on the ventricle: ventricular safety pacing triggered by right atrial lead dislodgement in a patient after right atrial tumor resection

Background Atrial lead dislodgment is not uncommon after permanent pacemaker implantation, especially in patients with atrial anatomic abnormity. Unique electrocardiography manifestation might give clues for promptly diagnosis. In patients with reconstructed right atrium, optimal pacing strategies and lead stability remain challenging. Case presentation A 44-year-old woman developed symptomatic sinus node dysfunction after right atrial tumor resection and reconstruction. A dual-chamber pacemaker was implanted, resulting in symptom resolution. At routine follow-up, electrocardiography showed ventricle was intermittently captured by one initial pacing artifact which was immediately followed by another pacing artifact at a fixed interval of 110-ms, consistent with ventricular safety pacing. Device interrogation revealed normal ventricular lead parameters but loss of atrial capture. Imaging confirmed atrial lead dislodgement into the right ventricle. The atrial lead was subsequently extracted and the device was reprogrammed to VVI mode. After 3 months follow-up, the patient remained asymptomatic and was with normal cardiac function. Conclusion This case highlights the importance of diagnostic role of electrocardiography to detect lead dislodgement. In patents with surgically altered right atrium, individualized pacing strategies, such as single-chamber ventricular pacing, may be appropriate. Novel atrial pacing lead with fix helix or leadless pacing might do some help to reduce the risk of dislodgement.