Pneumopericardium and Pneumomediastinum as a Late Complication of Defibrillator Implantation after Coronary Artery Bypass Graft Surgery

Abstract

A 69-year-old male underwent implantation of a cardioverter-defibrillator with cardiac resynchronization therapy (CRT) for symptomatic ventricular tachyarrhythmia (VT) and severe left ventricular (LV) dysfunction with an ejection fraction (EF) of 30 % and dyssynchrony via a left subclavian venous access. Twenty days after the procedure, the patient complained of shortness of breath and was found to have a 30 % apical left pneumothorax on chest X-ray as a not unusual complication of the subclavian venous access. A computed axial tomography of the chest revealed pneumopericardium and associated pneumomediastinum as a complication of the CRT implantation and persisting microscopic pleuro-pericardial fistula as a consequence of previous coronary artery bypass graft surgery (CABG), accidentally diagnosed three years after the procedure. The pneumothorax and pneumopericardium were small and did not require chest tube placement. The patient was treated conservatively and his subsequent course was excellent.

Pneumopericardium and Pneumomediastinum After Implantation of a Cardiac Resynchronization Pacemaker

“…Given the history of previous cardiac surgery in this patient, we hypothesized that air from the pneumothorax tracked into the pericardium and mediastinum through microscopic pleuropericardial fistulae, resulting from the previous surgery. To the authors’ knowledge, this complication has been reported only once before but as a late rather than as an early complication of device implantation (11). Importantly, spontaneous pneumomediastinum can normally be managed conservatively, with good prognosis (9).…”

Pneumothorax leading to pneumopericardium after transvenous lead implantation in a patient with previous epicardial lead

“…Pneumopericardium occurring after device implantation is rare, with literature limited to anecdotal case reports. The mechanisms to explain development of pneumopericardium after device implantation have been variously proposed on a case to case basis 3–9 . Perforation of the helix of the right atrial lead into the right pleural cavity through the atrial wall and pericardium can cause pneumopericardium with right pneumothorax, especially with active fixation leads being implanted in thin, frail, and elderly patients 3–6 .…”

“…Chen et al reported partial absence of the left pericardium as the cause of such a pleuropericardial connection 7 . It has been hypothesized that pleuropericardial microfistulae may form in patients who have undergone previous cardiac surgery 8,9 . Thus, in patients with previous history of cardiac surgery, these connections can then track air and consequently result in a pneumopericardium in case a pneumothorax occurs.…”

“…proposed on a case to case basis. [3][4][5][6][7][8][9] Perforation of the helix of the right atrial lead into the right pleural cavity through the atrial wall and pericardium can cause pneumopericardium with right pneumothorax, especially with active fixation leads being implanted in thin, frail, and elderly patients. [3][4][5][6] This is the most common mechanism reported for pneumopericardium after cardiac implantable electronic device (CIED) implantation.…”

Cardiovascular Implantable Cardioverter Defibrillator-Related Complications: From Implant to Removal or Replacement: A Review

“…However, isolated pneumopericardium reported as an exclusive complication of a cardiac resynchronisation therapy (CRT) implantation is very uncommon. We have previously reported pneumothorax recognised days after CRT implantation and concomitant pneumopericardium secondary as a late complication of a persisting connection between the pericardium and the pleura parietalis as consequence of the former aortal-coronary surgery, three years after coronary artery bypass graft surgery (CABG) (Fig.1, Parahuleva et al, 2009). …”