From Technical Pitfall to Clinical Consequences: Leadless Pacing as a Rescue Solution

Background: and Clinical Significance: Early lead failure after dual-chamber pacemaker implantation is rare but clinically significant, particularly when associated with throm-boembolic complications. Technical pitfalls at the time of implantation, such as suture fixation without protective sleeves, may predispose to premature lead damage and abrupt device malfunction. This case highlights the role of device interrogation in diagnosing arrhythmia-related stroke, the challenges of reimplantation in the setting of venous oc-clusion and anticoagulation, and the value of leadless pacing as a safe rescue strategy. Case Presentation: A 78-year-old man with a history of complete atrioventricular block underwent dual-chamber pacemaker implantation one year earlier. He presented to the emergency department with acute aphasia, right-sided hemiparesis, and facial asym-metry. Stroke was diagnosed, and new-onset atrial fibrillation was documented. Device interrogation revealed an abrupt fall in lead impedance followed by a sharp rise con-sistent with lead insulation failure and premature battery depletion. Fluoroscopy demonstrated multiple focal narrowings of the leads and complete left subclavian vein occlusion, making conventional transvenous reimplantation unfeasible, while extraction was judged high risk. Right-sided reimplantation was avoided due to hemorrhagic risk under anticoagulation. A leadless pacemaker was implanted successfully in the api-co-septal region of the right ventricle via ultrasound-guided femoral access. Hemostasis was secured with a figure-of-8 suture fixed inside a 3-way tap, providing constant com-pression and preventing hematoma. At one-month follow-up, device function was stable and neurological recovery was favorable (mRS = 2). Conclusions: This case underscores how multiple adverse factors—stroke, arrhythmia detection, early device failure, venous occlusion, and anticoagulation—may converge in a single patient, and demonstrates leadless pacing as a lifesaving bailout strategy in such complex scenarios.