Clinical Practice and Cases in Emergency Medicine

Case Presentation: Temporary transvenous pacemaker placement is frequently performed in the emergency department for the management of symptomatic bradyarrhythmias. We report the case of a 93-year-old male who presented with profound bradycardia, hypotension, and altered mental status requiring emergent pacing. Initial transcutaneous pacing achieved hemodynamic improvement but necessitated escalation to transvenous pacing due to patient discomfort and high current requirements. During attempted transvenous pacemaker placement, resistance was encountered and capture could not be achieved despite appropriate technique. Subsequent cardiology consultation and imaging revealed an undiagnosed tricuspid valve myxoma obstructing catheter advancement.

Discussion: This case highlights a rare mechanical complication of transvenous pacemaker placement caused by an intracardiac mass. Awareness of structural cardiac pathology as a potential cause of pacemaker placement failure is critical, particularly when resistance is encountered despite correct procedural technique