Simple leads to complex solutions.

To cite: Sheridan M, Kirubakaran S. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2014208869 DESCRIPTION A 76-year-old woman on warfarin for atrial fibrillation presented for routine pacing check 6 weeks after implantation of a dual-chamber device. She felt weak and generally unwell. The atrial lead was not sensing or pacing at high outputs. A chest X-ray showed the lead had perforated the atrial wall (figure 1). Echocardiography showed no pericardial effusion. International normalised ratio was 2.4. In light of these findings, urgent lead revision was planned in a centre with cardiothoracic facilities due to the increased risk of pericardial effusion and tamponade. Although pacemaker malfunction can be complex, simple non-specialist investigations can elucidate causes and majorly impact management.