An Unusual Cause of Localised ST Elevation following Insertion of a Permanent Pacemaker.

Localised ST elevation, chest pain and dyspnoea usually indicate ST elevation myocardial infarction. This 81-yearold female presented with worsening chest pain and dyspnoea four days post-insertion of a dual chambered pacemaker for sick sinus syndrome on Apixaban thromboprophylaxis for atrial fibrillation. Her background included unrepaired atrial septal defect, moderate to severe right ventricular (RV) dilatation and pulmonary hypertension. Her systolic blood pressure was 120 mmHg and heart-rate 80bpm, JVP was elevated at 9 cm. Electrocardiogram revealed dynamic inferior ST elevation of 1.5-2 mm. Urgent coronary angiography demonstrated minor coronary artery disease, however it was noted that the ventricular pacing lead tip appeared unusually leftward. This prompted an urgent transthoracic echocardiogram (TTE) that revealed a large global pericardial effusion with diastolic RV collapse and confirmed lead perforation through the anterior RV free wall (Figure 1).