Large Unilateral Pleural Effusion with Pacemaker-associated Post-cardiac Injury Syndrome

Abstract

Post-cardiac injury syndrome (PCIS) as a delayed complication of permanent pacemaker implantation has rarely been reported in the literature. A 67-year-old man who recently underwent a dual chamber permanent pacemaker implantation came to the hospital for increasing dyspnea and chest discomfort. A diagnosis of pericarditis was made, and the patient was discharged on ibuprofen therapy. He presented to our facility a month later with worsening dyspnea and chest discomfort despite recommended therapy. A computerized tomography (CT) scan of the chest revealed a large right-sided pleural effusion, requiring chest tube placement and drainage. A pleural fluid analysis revealed exudative effusion with elevated pH. The pleural fluid analysis was negative for infectious etiology. A perforation of the atrial wall was considered given the proximity of the atrial pacer lead and overlying pericardial effusion. However, no conclusive evidence of cardiac chamber perforation was found on echocardiogram or CT scan. A pacemaker interrogation was normal. A repeat CT scan showed the resolution of pleural effusion, and the chest tube was discontinued. A possible explanation for the absence of predominant pericardial findings may be the previous use of non-steroidal anti-inflammatory therapy.

A Rare Case of Acute Pleuropericarditis as a Complication of Permanent Pacemaker Insertion

“…After nonsteroidal anti-inflammatory drugs (NSAIDs) therapy (naproxen and colchicine), the patient was discharged, and at follow-up 1 month later there was no sign of recurrent pericardial effusion. Additionally, Kumar et al [ 10 ] described pleuropericarditis after IPG implantation. Firstly, pericarditis was diagnosed 2 weeks after the IPG insertion, and ibuprofen was used.…”

“…PCIS is an inflammatory process involving the pericardium and pleura in response to cardiac injury. The mechanism of IPG-induced PCIS is still unclear but may involve localized micro-trauma at the site of IPG lead insertion [ 10 ]. The increased incidence of PCIS with atrial leads is likely related to the thin atrial wall.…”

A case report of pleuro‐pericardial effusion in a patient on hemodialysis and a cardiac pacemaker

“…High pleural fluid pH (normal pleural fluid pH 7.6-7.66) may be an important parameter to consider PCIS as a cause of PLEF over an infection, in an appropriate clinical setting. 7,8 In one study, 12 out of 16 patients with PCIS, PLEF were bloody and exudative, with a pH greater than 7.40. 7 Majority of the patients with PCIS have benign course, and PPEF don't recur, especially after appropriate use of anti-inflammatory drugs like colchicine.…”

“…PLEFs in PCIS are usually exudative and rich in lymphocytes. High pleural fluid pH (normal pleural fluid pH 7.6–7.66) may be an important parameter to consider PCIS as a cause of PLEF over an infection, in an appropriate clinical setting 7,8 . In one study, 12 out of 16 patients with PCIS, PLEF were bloody and exudative, with a pH greater than 7.40 7 .…”

Postpericardiotomy syndrome after cardiac surgery

“…Although PPS most commonly occurs after cardiac surgeries and especially frequently after the most extensive procedures, numerous case reports concerning more unusual triggers of PPS have been previously published. A picture similar to PPS has followed penetrating injuries of the chest [52,88,89], gunshots of the thoracic area [52,90,91], nonpenetrating trauma to the chest [92][93][94][95], left ventricular puncture [96,97], pulmonary embolism [98], pacemaker implantation with epicardial leads [99][100][101], transvenous pacemaker implantation [40,41,[102][103][104][105][106][107][108][109][110][111][112][113][114], coronary artery perforation during balloon angioplasty [115], uncomplicated coronary angioplasty and stenting [116][117][118][119][120][121][122][123][124], percutaneous mitral balloon valvuloplasty [125], atrial radiofrequency ablation [126][127]…”