Case
A 44-year-old lady was admitted with worsening heart failure symptoms
for 1 month. She was a diagnosed case of idiopathic dilated
cardiomyopathy with severe left ventricular (LV) dysfunction and had
undergone cardiac resynchronization therapy defibrillator (CRT-D) device
implantation 1 year ago, at another centre. At that time, the LV lead
implantation could not be performed by the transvenous route due to a
large iatrogenic coronary sinus dissection and an epicardial LV lead was
subsequently implanted. She responded well initially, but after 6
months, her symptoms recurred. Device interrogation revealed epicardial
lead failure, necessitating a lead revision. At this time she was
referred to us.
We planned to implant the LV lead via the transvenous route. A left
coronary angiogram in the venous washout phase revealed a normally
flowing coronary sinus without any evidence of residual dissection. A
left arm venogram showed patent left axillary and subclavian veins. The
patient underwent a coronary sinus lead implantation successfully and
the epicardial lead was capped and sutured to the pocket. Of note, the
pocket had many adhesions and the left axillary/subclavian vein puncture
was particularly difficult,necessitating multiple attempts.
A good electrocardiographic result with narrowing of QRS complex,
prominent R wave in lead V1 and superior QRS axis were obtained.
However, the patient complained of deteriorating dyspnoea the next day.
Examination was suggestive of left pneumothorax with diminished breath
sounds and tympanic note on percussion. Chest X-ray confirmed the
diagnosis of a large left pneumothorax and surprisingly also revealed a
pneumopericardium. A left pleural drian was immediately placed(Figure 1a) . Transthoracic echocardiography was inconclusive
due to a poor window, but the Doppler derived hemodynamics were not
suggestive of cardiac tamponade. To help clarify the cause of
pneumopericardium a CT scan of the chest was performed, which confirmed
the presence of pneumopericardium, along with extrathoracic emphysema(Figure 2) . It further revealed a connection between the left
pleural and pericardial cavities around the epicardial lead, which
allowed air to track from one to the other. The chest X-ray three days
after intercostal drainage revealed resolution of pneumopericardium and
pneumothorax (Figure 1b) and the patient was subsequently
discharged. The patient continued to do well on follow up after 6
months.