An 80-year-old woman was referred to the cardiology department with a history of syncope. She had a background of left breast carcinoma with wide local excision and radiotherapy in 2007. Her 24 h electrocardiogram (ECG) showed sinus node disease with pauses of up to 5 s. A dual chamber permanent pacemaker was implanted via the left subclavian route without any immediate complications. Six days following the procedure she presented with a swelling at the site of the pacemaker. Under the assumption this was a haematoma, the swelling was aspirated under aseptic technique. Surprisingly, we obtained approximately 60 ml of white “milky” fluid (figs 1 and 2). Analysis revealed protein 31 g/, amylase 40 iu/l, triglycerides 18.44 mmol/l, with no bacterial growth.

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Figure 1

Pacemaker related swelling.

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Figure 2

Aspiration of “milky” fluid.

Chylous fluid collection in the pacemaker pocket has not previously been reported to our knowledge. The thoracic duct usually drains into the junction of the left subclavian and internal jugular vein (IJV). However, the anatomy is extremely variable and can also drain into the left IJV, left subclavian vein, left brachiocephalic vein, or left external jugular vein. With the background of left breast radiotherapy it is possible that the local anatomy may have been altered. Injury to the thoracic duct resulting in chylothorax is well described, but in our patient the fluid appears to have tracked into the subcutaneous pocket. We managed this unusual complication by aspiration of the fluid and application of a pressure dressing to the site. At the current time (3 months on) there has been no further recurrence of swelling.