Abstract 13553: Traumatic Right Atrium Perforation Causing Pneumopericardium and Pneumothorax, Treated Conservatively

Abstract

Background: Pneumopericardium after pacemaker implantation is an extremely rare complication. Patients can present with symptoms such as chest pain, shortness of breath, or be completely asymptomatic. We present a case of a 68-year-old male who underwent dual chamber pacemaker implantation complicated by a pneumopericardium and contralateral pneumothorax. Case Report: A 68-year-old male with a past medical history of coronary artery disease status post percutaneous coronary intervention to the obtuse marginal artery and left circumflex, hypertension and benign prostatic hyperplasia presented with syncope while driving. Telemetry showed symptomatic long pauses up to 6.2 seconds and a dual chamber pacemaker implantation was recommended via the left subclavian vein approach. It was noted that the patient had multiple attempts to place the right atrium lead. Two days after the procedure, the patient developed severe right-sided chest pain and an electrocardiogram showed diffuse ST segment elevations consistent with pericarditis. A chest computed tomography (CT) showed a large right-sided pneumothorax and pneumopericardium and a chest tube was placed. The pacemaker was interrogated and showed a stable function and the patient was managed conservatively. A repeat CT chest showed significant improvement in both the pneumopericardium and the pneumothorax and the patient did well on follow up. Discussion: Ipsilateral pneumothorax and cardiac perforation are not uncommon following pacemaker implantation; however, contralateral pneumothorax and pneumopericardium are extremely rare. In our patient, it appears that the right atrium lead perforated through the right atrium into the right pleural space creating a fistula between the pericardial and pleural spaces. This was not detected on the initial chest x-ray and was only seen on subsequent CT chest imaging. Treatment of pneumopericardium usually involves lead revision or extraction; however, conservative therapy can be successfully attempted with close monitoring, as in our case.