KEY TEACHING POINTS.

•After pacemaker implantation, acute heart perforations can be asymptomatic when they have an atypical location. Computed tomography is useful for identification of such complications. •Heart perforations by a pacemaker lead can be successfully managed by using a totally thoracoscopic approach in hemodynamically stable patients. •The hybrid approach allows simultaneous repair of the heart structure perforation and correction of the pacemaker lead displacement with physiological pacing recovery.