An unusual cause of a haemothorax following pacemaker implantation: A case report

Abstract

Background Haemothoraces are a reported but extremely rare complication of pacemaker implantation. Haemothoraces can be a consequence of lead perforation through the right ventricle (RV) and pericardium into the pleural space, direct lung or vascular injury during access. Case Summary A 72-year-old woman presented 24 hours after a pacemaker implantation with chest pain and shortness of breath. Computed tomography of the chest confirmed perforation of the RV lead into the left pleural cavity with a large left sided haemothorax. Following percutaneous drainage of the left sided haemothorax the patient became haemodynamically unstable necessitating emergent sternotomy. During surgery the extra-cardiac portion of the pacing lead was cut, the RV repaired and a large haematoma evacuated from the left pleural space. Despite this the patient remained hypotensive and further exploration showed a bleeding intercostal artery that had been lacerated by the pacing lead. This was treated by electrocautery and the patient’s haemodynamic status improved. The RV lead remnant was removed transvenously via the subclavian vein and the patient was left with a single chamber atrial pacemaker. Discussion Prompt recognition of RV lead perforation and its associated sequalae, often utilising multi-modality imaging, is vital to enable transfer to a centre with cardiac surgical expertise. In this case the perforating RV lead lacerated an intercostal artery and this was only identified at the time of surgery. In order to minimise the risk of perforation multiple fluoroscopic views should be used and care should be taken during helix deployment.

Right ventricular lead perforation with iatrogenic injury to an intercostal artery causing haemothorax after pacemaker implant

“…Lead perforation with pleural space penetration and direct injury to the left lung or intercostal artery has been reported with both atrial and ventricular leads 8–10. Saunderson et al described a case similar to ours, but with injury to an intercostal artery first identified during thoracic surgery when the patient remained hypotensive after the right ventricle was repaired 11. Forleo et al reported a case of massive acute haemothorax resulting from intercostal artery laceration subsequent to lead perforation 10 months postimplantation 12.…”

“…There have also been case reports of right haemopneumothorax due to right atrial lead perforation 13 14. Despite these documented occurrences, this complication remains relatively unknown among clinicians 11…”

“… 13 14 Despite these documented occurrences, this complication remains relatively unknown among clinicians. 11 …”

Very late perforation of a passive fixation lead 8 years after pacemaker implantation

“… 4 Lead perforations cause not only pacing/sensing failure but also pericardial effusion, cardiac tamponade, 1 and injury to the lungs and intercostal vessels. 5 In the present case, we speculated that the existence of epicardial and pericardial fat worked as a plug and cushioned material between the lead and surrounding organs ( Figure 3 B), which would prevent injury to the surrounding organs.

Figure 3 Before and after lead perforation.

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A massive hemothorax resulted from injury to the left subclavian artery branch during pacemaker implantation: case report and literature review

“…Therefore, in addition to strict electrocardiogram monitoring,re-examination of chest X-ray within 6 hours may be helpful for early detection and treatment of such complications,especially for patients with difficult puncture process [3] . In addition,based on past case reports,the causes of hemothorax after pacemaker implantation include repeated puncture injury of vein,left subclavian artery and left internal mammary artery as well as guide wires through the heart and intercostal artery [2,[4][5][6] .And most of them were diagnosed by angiography and treated by stent implantation or thoracotomy.In our patient,because the patient and his family members did not agree with angiography and surgery at the beginning,sexual venography and VATS were not selected until the third day,and the injured vessels were finally stopped by endoscopic titanium clips.The patient's blood pressure was stable and the follow-up was good. This case has several implications.…”