THE DEADLY PACE

Abstract

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Myocardial perforation remains as a rare but important complication of pacemaker insertion. Perforation can occur acutely within 24 h after implantation, sub-acutely between 24 h to one month after implantation and chronically occurring more than one month after implantation. (Sidhu). Acute perforations are well described at medical literature, but chronic perforations are much less common and can be difficult to diagnose (Ahmed). This is the case of atypical presentation of a chronic right ventricular perforation caused by RV ICD lead presenting with tamponade and left sided compression atelectasis. CASE PRESENTATION: A 73-year-old Male with PMHx of A-Fib, CHF class II, A-HTN, NIDDM, RA, PUD, TAA, S/P ICD placement 3 months before presentation, that comes to the ED with pleuritic chest pain, dizziness, SOB and fatigue of 3 months of evolution. Patient states that the symptoms slowly worsened over the last 3 days. At physical examination was found with BP 90/40, HR 105 bpm, RR 21rpm Sat 95% in acute distress, using accessory muscles with muffled heart sounds and + JVD. COVID-19 Ag was negative. EKG shows sinus tachycardia and low voltage on precordial leads. A bedside echocardiogram shows large pericardial effusion with tamponade physiology, ventricular perforation and emergent pericardiocentesis was performed. A total of 515 ml of bloody pericardial fluid was removed and patient vital signs improves. Chest CT scan later confirmed the presence of pericardial fluid accumulation and left sided compression atelectasis. The ICD lead was removed and relocated at the ventricular septum to avoid ventricular perforation in the future. DISCUSSION: In rare circumstances when a large effusion develops over time, it may cause compression atelectasis of the surrounding bronchi and lung (Amin). Compression atelectasis caused by ventricular perforation are better described in cases of acute or subacute ventricular perforation at the medical literature. The most common presentation of chronic perforation is SOB and hypoxemia. This patient presentation after 3 months of ICD placement, with sudden onset cardiac tamponade and no hypoxemia is an atypical presentation of chronic ventricular perforation. The rapid fluid accumulation over time in the pericardium, is what causes that this space stretches to accommodate the excess fluid, that later cause a compression atelectasis of the surrounding bronchi and lung (Amin). CONCLUSIONS: This patient atypical presentation of ventricular perforation wasn't described before in the literature. Is very important not to assume that any perforation may the sequelae of a recent intervention and can present acutely like in this life-threatening clinical scenario. As clinicians we need to keep in mind that ventricular perforation may present with large effusion causing compression atelectasis, with or without tamponade physiology. REFERENCE #1: Sidhu B, Rajani R, Rinaldi C. Chronic Ventricular lead perforation: Expect the Unexpected. Clin Case Rep. 2019, 7: 455-468 REFERENCE #2: Ahmed A, Shokr M, Lieberman R. Subacute right ventricular perforation by pacemaker lead causing left sided hemothorax and epicardial hematoma. Case Reports in Cardiology. 2017: 1-5 REFERENCE #3: Amin H, Gyawali B, Chaudhuri D. A large pericardial effusion culminating in left lung collapse. Cureus. 2019, 11: e5287 DISCLOSURES: No relevant relationships by Jesse Aleman, source=Web Response No relevant relationships by Francisco Caraballo, source=Web Response No relevant relationships by Greisha Gonzalez Santiago, source=Web Response