Fatal elective DDD pacemaker implantation

The initial electrocardiogram obtained immediately after implantation of the dual chamber (DDD) pacemaker showed normal atrioventricular pacing with a premature atrial complex after every two beats and an expected left bundle branch block pattern (LBBB) (Fig. 1a). The repeat electrocardiogram showed a similar rhythm with an LBBB, but with concordant ST segment elevation in lead aVR and concordant ST segment depression in leads V2 to V6 (Fig. 1b). The patient developed a refractory cardiogenic shock and a coronary angiography was obtained, which revealed extensive three-vessel disease without thrombi or acute occlusions. Fluoroscopy did not show any signs of lead displacement. The patient died during emergency percutaneous coronary intervention