Contralateral pneumothorax and pneumopericardium after dual-chamber pacemaker implantation: Mechanism, diagnosis, and treatment

Postural Conversion Computed Tomography for the Diagnosis of Pneumopericardium due to Perforation by the Active Atrial Lead

“…The development of pneumothorax contralateral to the venous access site is rare after implantation of implantable cardiac electronic devices, and there have only been a few reports (1)(2)(3)(4). All previous cases of contralateral pneumothorax arose from perforation due to the active atrial lead (same mechanism as observed in the present patient).…”

“…Our rare case of pneumopericardium and pneumothorax contralateral to the venous access site after ICD implantation highlights several points. First, pneumopericardium and contralateral pneumothorax developed due to anterolateral perforation of the RA free wall by the active atrial lead, which is the same mechanism as in previous reports (1)(2)(3)(4). In general, the RA lead is positioned in the RA appendage with a low risk of perforation, but it sometimes needs to be positioned at the RA free wall, such as when the RA free wall is the only location with adequate sensing and/or pacing thresholds (noted in approximately 3% of all patients) (4).…”

Bilateral Pneumothorax Complicating Pacemaker Implantation, due to Puncture of the Left Subclavian Vein and Electrode Perforation of the Right Atrium

“…Leadless pacemakers seem to be associated with a slightly higher perforation risk. Implantable cardioverter-defibrillator (ICD) leads have a larger diameter and a higher rate of perforation, whereas cardiac resynchronization therapy defibrillator (CRTD)-implantation is associated with the highest risk of perforation [3,[6][7][8][11][12][14][15][16][17].…”

“…Clinically relevant and symptomatic perforation of the cardiac wall occurs mostly within one month after implantation and in 0.3%-1.2% of all pacemaker procedures [6,[11][12]15]. Surprisingly, pericardial effusion was seen in 10% when newly implanted patients underwent a systematic echocardiographic evaluation, but it resolved spontaneously and rarely required therapy although most cases were probably caused by perforation of an implanted lead [11].…”

“…Pneumothorax occurs in 1%-2% of all pacemaker operations, due to needle injury of the pleura typically when attempting to gain access to the subclavian vein [1][2][3][4][5]. Perforation of a pacemaker electrode through the cardiac free wall occurs in 1%-2% of pacemaker implantations, whereas electrode perforation of the pleura resulting in pneumothorax is very rare [5][6][7][8][9] (estimated less than 0.0001% of all pacemaker implantations).…”