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CLINICAL CASES
PNEUMOTHORAX AND SUBCUTANEOUS EMPHYSEMA AFTER PACEMAKER IMPLANTATION
12 3 2
Piotr J.Stryjewski , Agnieszka Kuczaj , Jadwiga Nessler , Ewa Nowalany-Kozielska
Russ J Cardiol 2015, 4 (120), Engl.: 47-48
http://dx.doi.org/10.15829/1560-4071-2015-04-47-48
Key words: pacemaker implantation, pneumothorax, subcutaneous emphysema.
1 2
cardiology Department, chrzanow city Hospital; 2nd Department of cardiology, Zabrze, Medical University of Silesia, Katowice; department of coronary disease, Institute of cardiology, Jagiellonian University Medical college, John Paul II Hospital, Krakow, Poland.
Corresponding author. Piotr Jozef Stryjewski MD, PhD; cardiology Department, District Hospital in chrzanow, Poland, Topolowa 16 St. 32-500 chrzanow, Poland, Tel.: +48-509-59-89-59, Fax: +48-32-624-72-58, e-mail: [email protected]
Received November 21, 2014. Revision received November 24, 2014. Accepted december 01, 2014.
ПНЕВМОТОРАКС И ПОДКОЖНАЯ ЭМФИЗЕМА ПОСЛЕ ИМПЛАНТАЦИИ ЭЛЕКТРОКАРДИОСТИМУЛЯТОРА
12 3 2
Piotr J.Stryjewski , Agnieszka Kuczaj , Jadwiga Nessler , Ewa Nowalany-Kozielska
Российский кардиологический журнал 2015, 4 (120), Англ.: 47-48
http://dx.doi.org/10.15829/1560-4071-2015-04-47-48
Ключевые слова: имплантация электрокардиостимулятора, пневмоторакс, подкожная эмфизема.
1cardiology Department, chrzanow city Hospital; 22nd Department of cardiology, Zabrze, Medical University of Silesia, Katowice; department of coronary disease, Institute of cardiology, Jagiellonian University Medical college, John Paul II Hospital, Krakow, Польша.
82-year-old patient with arterial hypertension and chronic obstructive lung disease was admitted to cardiac ward due to second — degree atrioventricular block in order to pacemaker implantation. A DDDR pacemaker was implanted via left subclavian vein puncture with use of active fixation leads for both atrial and ventricular pacing. Pacemaker control confirmed dual chamber stimula-
Figure 1A. chest X-ray acquired 24 hour after placement of dual chamber pacemaker showing left-sided pneumothorax (arrow) with a shift of the mediastinum to the right side of the thorax.
tion mode with appropriate electrical parameters of ventricular and atrial channel. At the next day after pacemaker implantation the patient became rapidly dyspneic. In chest X-ray posteroanterior examination left-sided pneumothorax with dislocation of the mediastinum to the right hemithorax was elucidated (Figure 1A). Decision of invasive pneumothorax removal was taken. Surgeon inserted
Figure 1B. chest X-ray — state directly after pneumothorax evacuation; in pleural space visible chest tube.
Russian Journal of Cardiology № 4 (120) Eng., 2015
Figure 1C. chest x-ray showing diffuse subcutaneous emphysema (arrows). Figure 1D. chest x-ray after 14 days — visible significant reduction of subcutaneous
emphysema.
chest tube into the pleural space. Control chest X-ray showed significant reduction of pneumothorax (Figure 1B). Pacemaker interrogation revealed no change in lead data. After 7 days of therapy the surgeon removed chest tube. The removal was followed by large subcutaneous emphysema occurrence (Figure 1C). During the next 14 days observed was gradual reduction of subcutaneous emphysema confirmed by serial chest X-rays (Figure 1D).
Pacemaker implantation is connected with potential risk of complications. The complications could be divided into acute — directly after implantation, early — up to 3 months and late — beyond 3 months. As acute complications considered are: pneumothorax, bleeding into pleural space, hematoma, heart wall or central vein perforation, diaphragm or skeletal muscle stimulation, electrode dislocation and inappropriate functioning of pacemaker or electrode. The long-term complications are: pacemaker pocket infection, thrombosis or occlusion
of vein with inserted electrodes, twiddler's syndrome. The presented patient had pneumothorax complicated by subcutaneous emphysema. The cause of pneumothorax occurrence was insertion of pacemaker electrodes via subclavian vein. More safe method of electrode placement seems to be cephalic vein preparation. Method of instrumental healing of pneumothorax is punction of pleural space with chest tube insertion — procedure that is also connected with a risk of complications.
Pneumothorax is usually a complication of percutaneous insertion to the subclavian vein. The clinical course of pneumothorax could be variable: from nearly asymptomatic to clinical course presenting with acute signs and symptoms such as dyspnea, chest pain, cyanosis and shock. In every case of patient with pneumothorax before chest tube insertion potential benefits and risk of complications accompanying the procedure should be considered.
