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Abstract
Implantation of cardiac devices is usually considered to be a safe procedure. Rare complications, such as pneumothorax, may occur after the procedure. The association with pneumopericardium or pneumomediastinum is even more uncommon. We present the case of a patient in his 70s, on haemodialysis, admitted for complete atrioventricular block. He underwent implantation of a dual-chamber pacemaker. He presented with chest pain the day after implantation. Chest CT scan revealed a pneumothorax associated with a pneumopericardium and pneumomediastinum ‘pan pneumo’, due to an atrial perforation. We opted for a conservative management strategy. Repeat CT scan of the chest 8 days after the procedure showed a complete resorption of the ‘pan pneumo’. The objective of this case report is to describe this rare complication and provide further insight into its management, particularly in the absence of specific guidelines.
- Pacing and electrophysiology
- Pericardial disease
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Background
Implantation of cardiac devices is usually considered to be a safe procedure. Rare complications, such as pneumothorax, may occur after the procedure; mainly caused by the needle during the subclavian vein puncture. The association with pneumopericardium or pneumomediastinum is even more uncommon. We describe a rare case of concomitant pneumothorax, pneumomediastinum and pneumopericardium ‘pan pneumo’ after pacemaker implantation via the right cephalic vein.
Case presentation
A male patient, in his 70s, on haemodialysis (with a left arteriovenous fistula) was admitted to our intensive care unit for complete atrioventricular block. Transthoracic echocardiography showed 50% left ventricular ejection fraction with no structural abnormalities.
A dual-chamber pacemaker was implanted and leads were placed via the right cephalic vein, (ACCOLADE DR L311 MRI Boston Scientific). The ventricular lead (INGEVITY MRI 7741 Boston Scientific) was fixed on the septum of the right ventricle. The atrial lead (INGEVITY MRI 7740 Boston Scientific) was initially fixed on the appendage, but was not stable, then was fixed on the free wall of the right atrium to improve stability. At implantation, the pacing threshold, sensing and the impedance of the ventricular and the atrial leads were satisfactory (right ventricular pacing threshold was 0.3 V at 0.4 ms, sensing was 9 mV and impedance was 760 Ω. The atrial pacing threshold was 0.3 V at 0.4 ms, sensing was 2.7 mV and impedance was 513 Ω). The patient presented with chest pain the day after implantation, that was not relieved by analgesics.
Investigations
ECG showed paced ventricular rhythm without significant repolarisation abnormalities. The Chest X-ray showed no pneumothorax and normal lead positions (figure 1). Device interrogation demonstrated no significant change in lead parameters. There was no pericardial effusion on echocardiogram.
X-ray of the chest in the anteroposterior view. No pneumothorax or haemothorax is seen. The right ventricular lead is fixed on the septum and the right atrial lead is fixed to the free wall.
Chest CT scan showed a right pneumothorax, associated with a pneumopericardium and a pneumomediastinum, due to perforation of the free wall of the right atrium by the tip of the atrial lead (figures 2 and 3).
(A) Axial CT scan showing right-sided pneumothorax (arrows) and pneumomediastinum. (B) Axial CT scan reveals pneumopericardium in addition to pneumothorax and pneumomediastinum.
Chest CT scan coronal view (A) and sagittal view (B) showing perforation of the anterolateral free wall of the right atrium by the screw of the lead (red circle).
Treatment
After multidisciplinary discussion, we opted for a conservative treatment strategy based on the small size of the ‘pan pneumo’ and the haemodynamic stability of the patient.
Outcome and follow-up
The patient underwent a CT scan 8 days later, showing a complete resolution of the pneumothorax, pneumopericardium and pneumomediastinum (figure 4). The patient was discharged home 12 days after pacemaker implantation. After 1 year of uneventful follow-up, he was doing well and free of symptoms.
Chest CT axial views (A,B) showing complete resorption of the pneumothorax, pneumopericardium and pneumomediastinum 8 days after the implantation.
Discussion
In France, 49 871 pacemakers and 10 343 defibrillators were implanted in 2019.1 The incidence of pneumothorax post device implantation is less than 1%,2 and the association with a pneumopericardium and/or pneumomediastinum is so uncommon that no accurate incidence is reported through the literature. Predictors of pacemaker implantation-induced pneumothorax include: age>80 years old, chronic obstructive pulmonary disease, implantation of dual-chamber devices, venous access by subclavian vein puncture and venous access by both subclavian vein puncture and cephalic vein cut-down.2 In our case, it was a cephalic access, and the ‘pan pneumo’ was caused by an atrial lead screw that perforated the free wall of the right atrium and extended to the pleura. Generally, the atrial lead is placed in the right atrial appendage, but it has been noted that in 3% of cases, the free wall of the atrium is the only position that allows satisfactory pacing parameters.3
The incidence of cardiac perforation following pacemaker or cardiac defibrillator implantation is around 0.4%–0.6%.4 It may manifest as chest pain, dyspnoea, or it may be asymptomatic. Its incidence likely remains underestimated, as postimplantation X-ray of the chest and pacing parameters could be normal even in the presence of perforation, as shown in our case and in other previous reports.5–7
Nevertheless, Hirschl et al demonstrated in their study of 100 patients that myocardial perforation is not as rare as we thought. They performed routine thoracic CT scans after pacemaker or defibrillator implantation in asymptomatic patients. The authors found that 15% of patients had a myocardial perforation, either at the ventricular or atrial level, while no significant difference in stimulation parameters was found between perforating and non-perforating leads.7 Rajkumar et al showed that CT scan is more sensitive for the diagnosis of iatrogenic pacemaker/defibrillator-induced cardiac perforation than echocardiography and X-ray of the chest.8 Given these data, physicians should not hesitate to perform a chest CT scan when suspecting myocardial perforation, even in the absence of abnormalities on echocardiogram and chest X-ray.
Up to date, there are no specific management guidelines for this rare complication. Sebastian et al performed chest drainage without repositioning the lead and they observed a regression of the pneumothorax and pneumopericardium.9 Srivathsan et al performed drainage combined with extraction of the atrial lead.10 For our patient, we adopted a conservative strategy, with close monitoring until complete air resorption on CT scan. Nantsupawat et al adopted similar approach with favourable outcome.5 The management strategy could be guided by the haemodynamic stability, the pneumothorax size, the severity of symptoms, the position of the lead and its stimulation parameters.
Learning points
Pan pneumo (concomitant pneumothorax, pneumomediastinum and pneumopericardium) is an extremely rare complication following pacemaker or cardiac defibrillator implantation.
Whenever possible, it is important to avoid positioning the lead at the level of the free right atrial wall.
Up to date, the guidelines do not include any specific management strategies for this rare complication.
Case management should be tailored based on the clinical and radiological findings as well as on the lead position and its stimulation parameters, within a multidisciplinary team including not only cardiologists and radiologists but also cardiothoracic surgeons.
Ethics statements
Patient consent for publication
Footnotes
Contributors All authors were responsible for drafting of the text, sourcing and editing of clinical images, investigation results, drawing original diagrams and algorithms, and critical revision for important intellectual content. All authors gave final approval of the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.