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The implantation cardiac rhythm management devices is rising annually. The two known common complications of these devices, infection and pneumothorax, occur in 1.2% and 0.6% of patients, respectively. Pneumothorax is usually seen in the ipsilateral part of implantation however in some rare cases this will be seen in the contralateral part. Despite using cephalic vein cutdown or venogram assisted puncture of axillary vein to reduce this complication, pneumothorax remains the one of the most morbid complications post implant. In this article a rare case of bilateral pneumothorax will be presented and discussed. KeywordsBilateral pneumothorax, implantable cardiac devices, cephalic vein cutdown Post procedure chest X-ray showed large bilateral pneumothorax, which was larger in the right side (Figure 1). The patient initially underwent an uneventful bilateral pleural drainage with pigtail which was unable to expand the lung adequately. He then underwent a bilateral chest tube which was followed by a third chest tube insertion in the middle of his chest due to lack of adequate lung expansion.A chest computed tomography (CT) scan was conducted to elucidate the mechanism of pneumothorax and any underlying pulmonary pathologies. This revealed communication between the right and left pleural spaces through the anterior mediastinum (Figure 2), which is not an uncommon finding after cardiac surgeries involving midline sternotomies.After five days, all tubes were removed, the chest X-ray showed full expansion of both lungs and the patient was discharged home. DiscussionAlthough ipsilateral pneumothorax is the most common complication of subclavian puncture with the incidence of 0.6-7.5%, 4 iatrogenic bilateral pneumothorax post median sternotomy has been previously reported.This issue has been first reported by Schorlemmer et al. in 1984 in a patient with previous median sternotomy who needed subclavian

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