Introduction: Placements of pacemakers have become a routine procedures and are generally associated with low complication rates. Late permanent pacemaker PPM lead perforation is an uncommon but clinically significant complication. Chest radiograph is most commonly used imaging modality to diagnose the lead perforation by following the lead tip position. Usually it is easier to diagnose if the lead tip is outside the cardiac shadow. We, describe an accidentally discovered cardiac and diaphragmatic perforation with the PPM lead in one of our patients. Case Description: A 70-year-old gentleman from a rural area underwent single chamber PPM implantation through left subclavian vein approach for treatment of sinus node dysfunction. He was discharged in good condition and pre-discharge PPM interrogation found loss of capture and intermittent sensing failure. Pre-discharge echocardiogram showed endocardial lead in situ. After 6 months he came to the outpatient clinic for follow up, chest-X ray showed that the pacemaker lead is outside the cardiac shadow perforating the right ventricle, pericardium and left diaphragmatic copula. CT scan with contrast of the chest confirmed the diagnosis. As the patient was asymptomatic and his ECG showed normal sinus rhythm, so after discussing the case the consensus was to take out surgically the whole PPM lead and the pulse generator as well. In the operating room after left sub-mammary incision we saw the lead outside the heart so it was cut and the remaining proximal part with the pulse generator was pulled out via the left subclavian incision. The right ventricle and the diaphragm were repaired and the patient tolerated the procedure well and discharged home after few days in a good condition. Conclusion: After PPM implantation, one should be aware of lead perforation. Interventricular septal fixation of the lead may decrease the incidence of perforations. The CT scan of chest should be done earlier to confirm the diagnosis in situations with high possibilities of lead displacement along with close observation.