An 88-year-old woman with advanced frailty and multiple comorbidities, including atrial fibrillation, ischemic heart disease, diabetes, recurrent falls, and haemochromatosis, presented in July 2023 with respiratory symptoms and haemoptysis. She had a complex pacemaker history, with multiple atrial leads implanted over the years and conversion to a single-chamber device in 2020 after lead insulation failure. Investigations revealed a fractured and embolized right atrial lead tip, visible on a March 2023 chest X-ray but unreported at that time. A CT thorax confirmed the detached metallic fragment located within the coronary sinus, originating from her original 2006 atrial lead. Echocardiography had previously shown bi-atrial dilatation, left ventricular hypertrophy, and moderate tricuspid regurgitation.

Given her significant frailty and comorbidities, consultation with cardiothoracic surgery determined that the risks of extraction—including pericardial effusion, pneumothorax, coronary sinus rupture, or cardiac perforation—far outweighed the potential benefits. The fractured lead was redundant, did not compromise pacemaker function, and the patient was already anticoagulated for atrial fibrillation, reducing concern for embolic risk. No alternative cause for her respiratory symptoms was identified on CT.

A conservative management plan was agreed, focusing on monitoring and coordination between her GP and pacing clinic rather than intervention. This case represents a rare occurrence of complete fracture and embolization of a redundant atrial lead screw tip, with the fragment unusually remaining stable in the coronary sinus over several months. Unlike previously reported cases where urgent extraction was pursued, this patient tolerated the fragment without acute deterioration, highlighting that in frail patients with multiple comorbidities, a conservative approach may be safer than high-risk surgical intervention. The case underscores the importance of individualized management, balancing procedural risks with overall prognosis and patient frailty.

Ala Al-Qudah is currently a medical specialty registrar in Royal Oldham Hospital, he is in the final year of his internal medicine training program. He is currently a masters student in cardiology in Buckingham University, UK.