Background pacemaker (PMK) implantation is a routinary procedure although it isn’t free from complications, some of with could be life–treathing. Case report: A female 84 years old with hypertensive cardiomiopathy and atrial fibrillation on anticoagulation theraphy with Dabigatran was subjected on a pacemaker implantation (29th Sept) for sick sinus syndrome (SSS) after syncope. The day after the implantation a chest radiography showed a left–apical pneumothorax (PNX) without necessity of surgical drain (fig. 1). Few days after (3th Oct) patient showed dyspnoea, desaturation and pain on left hemithorax so a chest CT was performed with detection of massive hydropneumothorax needed surgical drain. After 5 days a check CT was performed (9th Oct) showing resolution of the PNX but documented a circumferential 30 mm pericardial effusion “worthy of cardiological reevalutation” meanwhile the patient was hemodynamically stable. At echocardiographic look there was a pericardial effusion of 15 mm. After the re–evalutation of the CT imeges by a cardiologist, in the suspicion of myocardial perforation, patient were centralized in a cardio–surgery center. Transesophageal echocardiography evidenced a pericardial effusion of 19 mm with initial signs of haemodynamic impact and visualization of the lead in the percardual sac by 15 mm. The patient underwent (11th Oct) extraction of the ventricular lead in median sternotomy and epicardial reimplantation in a hybrid arrhythmological and cardiosurgery operating theater. Conclusions cardiac perforation and PNX are two serious but rare complication of PMK implantation with an incidence of 0,1% and 1%, but only anecdotally described together in the literature. The initial finding of PNX which was attributed the syntomatology was a confounding factor that delay the diagnosis of miocardial perforation. The unavailability of a programmer for interrogating the device didn’t allow early documentatio of the alteration of the electrical parameters. In the first CT of 3th Oct no pericardial effusion were reported but, from a retrospective analysis the images were alredy suggestive while they leave no doubts in the second radiological examination (fig 2,3).

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The Osborn wave is a deflection immediately following the QRS complex of the surface ECG. It can be observed in hypothermic patients. A 51-year-old man was admitted to the emergency department of our hospital because of loss of consciousness with tonic-clonic seizures. The cranial computerized tomography (CT) showed intraparenchymal hematoma. After neurosurgical intervention, during hospitalization, the electrocardiogram (ECG) showed the presence of a huge Osborn wave.