A 75-year-old white male patient, with hypertension and symptomatic sinus bradycardia after dual-chamber pacemaker placement (Adapta DR Pacemaker ADDR01, Medtronic, Minneapolis, MN, USA) 31 months previously, presented with severe headache and was found to have subarachnoid haemorrhage (SAH). A 12-lead electrocardiogram done for routine workup showed a right bundle branch block (RBBB) pattern and right axis deviation ( Fig. 1 ). A transthoracic echocardiogram showed that the right ventricular (RV) pacemaker lead had crossed the foramen ovale into the left atrium, passing through the mitral valve, and was embedded in the inferolateral wall of the left ventricle (LV) ( Fig. 1 ). A chest X-ray in lateral view showed an anteriorly directed lead in the LV. Management was a therapeutic dilemma; lead extraction was advised ( Fig. 1 ).
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