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.