Inadvertent endocardial lead malposition is recognised as a rare incident which is usually underreported and if recognised during implantation can be easily corrected. This phenomenon is caused by the ventricular lead unintentionally crossing a pre-existing patent foremen ovale, septal defects (atrial or ventricular) or directly from the aorta via an accidental subclavian puncture resulting in the lead implanting into the left ventricle. While this is a rare occurrence we report the incidental finding of pacemaker lead malposition during a routine follow-up transthoracic echocardiogram and the benefits of three dimensional transoesophageal echocardiography in this patient prior to lead extraction.