We report a rare case of RV perforation, pneumatocele and pneumothorax after a pacemaker lead placement, requiring partial lung resection.
RV perforation from pacemaker lead placement occurs rarely (0.3–3%) [1, 3,4,5]. In contrast to subacute perforation (24 h–1 month after implantation), acute perforation (within 24 h after implantation) with hemodynamic compromise warrants immediate attention. Surgery may be best chosen because of neighboring organ injury, or hemodynamic compromise due to acute cardiac tamponade in the setting of perforated lead removal [2, 6]. On the other hand, in stable conditions, simple direct traction can be considered under close echocardiographic monitoring and with a surgical backup [2, 3, 6]. Because the right heart is a low-pressure system, a perforation may be sealed by the lead itself and/or a combination of muscle contraction and fibrosis over the lead, with minimum sequelae [3, 4].
Strategies should depend on the dynamics of symptoms, pericardial effusion, hemodynamic status, and injured neighboring organs [2, 6].
When the patient is pacing-dependent, lead extraction should be followed by new lead placement in a different location, preferably in the RV outflow tract or the intraventricular septum. In the case of open-chest surgery, the implantation of epicardial leads may be considered [2].
RV lead replacement was avoided in our patient due to patent atrioventricular conduction, considering that the AAI pacing can achieve a clinical outcome similar to that of the DDD. Pneumothorax is a potential complication of vascular access during a pacemaker implantation (0.2–3.87%) [1, 5], frequently seen within the first 24 h after the implantation (1.3–3.87%) [5, 7]. On the other hand, pacemaker lead penetrating the myocardium and causing pneumothorax is rare and usually is found over 24 h after pacemaker implantation [3].
Generally, management of pneumothorax is guided by the amount of air and patient’s hemodynamic status [8]. A chest tube should be considered when the patient has respiratory distress, hemopneumothorax, or any pneumothorax larger than 20% of the hemithorax, irrespective of the symptoms [8]. Our patient presented with a pneumothorax that involved almost 10% of the pleural cavity.
Pathological analysis of the resected lung specimen revealed that the cystic space on CT imaging was a pneumatocele. Pneumatocele is an air-filled cystic cavity in the lungs, and frequently caused by severe pneumonia, blunt thoracic trauma, chronic obstructive pulmonary disease, or hydrocarbon ingestion with aspiration [9,10,11,12]. Although several mechanisms have been proposed for the development of pulmonary pneumatocele, the exact reasons are unknown [9,10,11]. On the other hand, pneumatoceles may occur when bronchial injury or inflammation creates a check-valve mechanism for air entry into the lung parenchyma [9, 11, 12]. In general, pneumatocele is a benign, self-limited condition that rarely requires surgical intervention [13]. However, life-threatening tension pneumatocele with rapid enlargement can result in rupture and pneumothorax. Secondary infection may require surgical interventions [10, 12]. There are no well-established or widely accepted treatment algorithms for pneumatocele [12, 13].
Pneumatocele due to RV pacemaker lead perforation has scarcely been reported, thus, standard of care remains to be determined. In the present case, surgery was chosen because of its potential for infection and pneumothorax, and surgery has better outcomes to avoid recurrent pneumothorax, compared with conservative treatment [14].
