An 87-year-old man presented at the hospital with shortness of breath and syncope. His medical history included ischemic heart disease, emphysema, and hypertension. An electrocardiogram showed complete heart block and nonsustained polymorphic ventricular tachycardia. A temporary ventricular pacing wire was inserted. In the coronary care unit, the patient was treated for a community-acquired chest infection. A dual-chamber permanent pacemaker (PPM) was inserted by means of left cephalic vein cutdown. Active-fixation leads were used. After implantation, a device check, lead check, and chest radiograph revealed nothing abnormal.
Eight days later, the patient had dyspnea and hemoptysis. A chest radiograph showed patchy consolidation in the lower zone of both lung fields, the right atrial pacing lead's tip situated outside the cardiac silhouette, and evidence of pneumopericardium (Fig. 1). At the regional cardiology center, the right atrial pacing lead was uneventfully removed and replaced with a passive-fixation lead. The patient was discharged from the center 3 days later.
Fig. 1.
Chest radiograph shows an extracardiac location of the right atrial pacing lead tip (arrow) and pneumopericardium. The arrowhead indicates the pericardial outline.
Comment
Permanent pacemaker implantation is associated with a complication rate of approximately 7%.1 Typical sequelae are pocket hematoma, pneumothorax, lead displacement, tamponade, and infection.2 Pneumopericardium is a very rare sequela that can progress to tension pneumopericardium and cardiac tamponade.3
Cardiac perforation after PPM implantation is also infrequent (incidence, <1%).1 Associated symptoms, often nonspecific, include extracardiac muscle stimulation, chest pain, dyspnea, dizziness, and fatigue.4 Cardiac perforation might occur more often when active (rather than passive) fixation leads are used.5 Additional risk factors include older age, corticosteroid use, and temporary pacing.6
Our patient's cardiac perforation was associated with pneumopericardium, which most likely resulted from acute protrusion of the atrial pacing lead through the pericardium into the pleural space or lung parenchyma. This case illustrates an infrequent but important sequela of PPM implantation. Careful inspection of the chest radiograph is essential when a patient becomes symptomatic early after the procedure.
Footnotes
Section Editor: Raymond F. Stainback, MD, Department of Adult Cardiology, Texas Heart Institute, 6624 Fannin St., Suite 2480, Houston, TX 77030
From: Cardiology Department (Dr. Roberts), Royal Victoria Hospital, Belfast BT12 6BA; and Cardiology Department (Drs. Flannery, Hennessy, McConville, and McKeag), Craigavon Area Hospital, Portadown BT6 3QQ; Northern Ireland, United Kingdom
References
- 1.Kiviniemi MS, Pirnes MA, Eranen HJ, Kettunen RV, Hartikainen JE. Complications related to permanent pacemaker therapy. Pacing Clin Electrophysiol. 1999;22(5):711–20. doi: 10.1111/j.1540-8159.1999.tb00534.x. [DOI] [PubMed] [Google Scholar]
- 2.Rajappan K. Permanent pacemaker implantation technique: part I: arrhythmias. Heart. 2009;95(3):259–64. doi: 10.1136/hrt.2007.132753. [DOI] [PubMed] [Google Scholar]
- 3.O'Neill R, Silver M, Khorfan F. Pneumopericardium with cardiac tamponade as a complication of cardiac pacemaker insertion one year after procedure. J Emerg Med. 2012;43(4):641–4. doi: 10.1016/j.jemermed.2010.04.026. [DOI] [PubMed] [Google Scholar]
- 4.Refaat MM, Hashash JG, Shalaby AA. Late perforation by cardiac implantable electronic device leads: clinical presentation, diagnostic clues, and management. Clin Cardiol. 2010;33(8):466–75. doi: 10.1002/clc.20803. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Sterlinski M, Przybylski A, Maciag A, Syska P, Pytkowski M, Lewandowski M et al. Subacute cardiac perforations associated with active fixation leads. Europace. 2009;11(2):206–12. doi: 10.1093/europace/eun363. [DOI] [PubMed] [Google Scholar]
- 6.Mahapatra S, Bybee KA, Bunch TJ, Espinosa RE, Sinak LJ, McGoon MD, Hayes DL. Incidence and predictors of cardiac perforation after permanent pacemaker placement. Heart Rhythm. 2005;2(9):907–11. doi: 10.1016/j.hrthm.2005.06.011. [DOI] [PubMed] [Google Scholar]