Abstract
Cardiac pacemakers are widely used, and lead perforation is a rare but serious complication that may present atypically, leading to diagnostic challenges. We present the case of a 79-year-old male with a history of multiple comorbidities, including heart failure with preserved ejection fraction, right bundle branch block, and recent dual-chamber pacemaker implantation, who developed persistent left upper quadrant abdominal pain. Despite multiple ED visits and specialist evaluations, no clear etiology was identified. Previous outside hospital diagnostic workups, including electrocardiography, chest radiography, and CT, failed to reveal an acute cause for his symptoms. Ultimately, CT imaging in our ED demonstrated migration of the right atrial pacemaker lead, with positioning suggestive of myocardial perforation. The patient was admitted for further management, remained hemodynamically stable with pain controlled, and was conservatively monitored without immediate intervention. Myocardial perforation due to pacemaker leads can occur acutely, subacutely, or as a delayed complication. While early perforation may be identified during implantation or shortly thereafter, subacute and chronic cases often present with non-specific symptoms, making diagnosis challenging. Imaging modalities such as CXR, echocardiography, and CT play a critical role in identifying lead migration. Management strategies range from conservative observation in stable patients to surgical or transvenous lead extraction in symptomatic or high-risk cases. This case stresses the importance of considering pacemaker-lead migration as a potential etiology in patients presenting with unexplained pain after implantation. It also highlights the limitations of conventional diagnostic tools and the value of advanced imaging techniques, such as CT, in the timely identification of this complication.