Pneumopericardium and Pneumomediastinum After Implantation of a Cardiac Resynchronization Pacemaker

Abstract

A patient with previous coronary artery bypass grafting developed an iatrogenic pneumothorax, along with pneumopericardium and pneumomediastinum, after elective implantation of a cardiac resynchronization therapy pacemaker. There was no evidence of lead perforation, and the patient remained well and was successfully managed conservatively. We hypothesize that air tracked from the pneumothorax via microscopic pleuropericardial fistulae. (Level of Difficulty: Intermediate.)

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.…”

“…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…”

When Uncontrolled, Air Can Give You a Hard Time

“…In this issue of JACC: Case Reports , Green and Herring (1) refer to the case of an 84-year-old male patient with a history of a coronary artery bypass graft 24 years earlier. The patient was admitted for permanent pacemaker implantation; a cardiac resynchronization therapy−P system was implanted through direct left subclavian puncture.…”