Tarek M Mousa, M.D., Mustafa Salehmohamed, D.O. Kwok Yim, P.A., Terence Brady, M.D., F.A.C.P., Robert Fleming, M.D., F.A.C.P.
A 70-year-old male patient with ischemic cardiomyopathy underwent an intracardioverter defibrillator (ICD) implantation for primary prophylaxis. On a regular post procedure follow up 3 days later the patient reported having mild shortness of breath and cough. Chest radiography showed a right side pneumothorax (PNX). A thoracostomy tube was inserted and a CT scan of the chest was done to investigate the etiology of the PNX. CT suggested a protruding tip of the right atrial lead into the right pleural space. However, the findings were not conclusive due to a metallic and a movement artifact and the lead was not extracted. It was felt that lead fibrosis had already begun and that it would seal the site of perforation especially after ICD interrogation revealed satisfactory atrial and ventricular sensing and pacing thresholds and lead impedance. This conservative approach was adopted and has been successful in 3 previous case reports of the similar complication. Five days later the patient presents to the ER complaining of worsening shortness of breath associated with substernal chest discomfort, facial and neck swelling. Subcutaneous emphysema and crepitus was noted at the right lateral chest wall extending down to the right flank with diminished air entry on the right lung field. Chest radiograph revealed no PNX, but severe subcutaneous emphysema on the right and left aspects of the neck (more pronounced on right side), right shoulder, and right lateral aspect of chest wall. A thoracostomy tube was inserted with and a CT scan of the chest with 3-D reconstruction confirmed the plain radiographic findings in addition to showing a right side PNX, pneumomediastinum, and the right atrial lead of the ICD protruding outside the cardiac chamber into the pleural space. Patient then underwent repositioning of the right atrial lead and the right PNX sealed without complications and the patient was sent home. On his follow-up visits, he remains asymptomatic and chest radiographs and ICD interrogation were unremarkable. We are reporting the first case with recurrent PNX secondary to right atrial lead perforation after adopting a conservative approach in management. This strategy, however, did not appear to be optimal in our case as the patient had a recurrence of his PNX. As this case demonstrates, with detection of contralateral PNX to the site of venous access after pacemaker/ICD placement, consider atrial lead perforation as the etiology of the PNX and a 3-D reconstruction CT maybe a helpful diagnostic tool.