An 81‐year‐old woman comes to the emergency department with acute‐onset shortness of breath and left‐sided, nonradiating chest pain. A month prior, she had a dual‐chamber pacemaker implantation for a diagnosis of sick sinus syndrome. There were no subsequent complications related to the procedure, except for a small pericardial effusion on the following echocardiogram. The patient did well until she began noticing exertional dyspnea. Her medical history was significant for chronic lymphocytic leukemia (CLL), hypertension and osteoporosis. She was admitted to the hospital. Physical examination showed an elderly woman experiencing mild shortness of breath with no Kussmaul sign, audible, regular heart sounds with a 2/6 systolic ejection murmur across the left sternal border, no rubs, and decreased breath sounds at the bases bilaterally. The echocardiogram showed a large pericardial effusion without evidence of tamponade. Pacemaker interrogation was immediately arranged and showed lack of atrial capture, even with high voltage. The patient had a pulsus paradoxus of only 8 mm Hg, but given that she was symptomatic and with a previous history of CLL, therapeutic pericardio‐centesis was performed. Malignant pleural effusion was strongly suspected. A repeated cardiac CT scan suggested possible perforation of the right atrium. Given these findings, elective extraction of the atrial pacing lead with implantation of a new passive right atrial pacing lead was done. The remainder of the patient's hospital course was uneventful, and she was discharged home.
Pacemaker implantation is a fairly benign procedure. Acute perforation of the myocardium during the placement of pacemaker leads happens in 1%‐7% of patients. On the other hand, late perforation of the pacemaker leads is an additional rare complication, and it is associated with a varied time frame from days to months. Permanent pacemaker implantation may be complicated by cardiac perforation, which can lead to longer hospital stays, pericardial effusion, tamponade, or even death. Atrial perforation symptoms depend on the displaced electrode position, sensing threshold, and failure of pacing. The clinical manifestations of significant perforations are variable and include chest pain, dyspnea, and hypotension, corresponding to the usual symptoms of pericardial effusion or, more seriously, tamponade. However, one of the distinguishing features of delayed lead perforation as opposed to acute lead perforation is the decrease or absence of cardiac tamponade or death. Lack of atrial capture even with high voltage is a characteristic finding of perforation.
This case is shared to remind hospitalists to consider this rare cause of very common presenting symptoms: acute chest pain and shortness of breath. In a similar clinical context, they are encouraged to suspect myocardial wall perforation rather than malignant or other causes of peri‐cardial effusions.
I. L. Ponor ‐ none; S. M. Eid ‐ none
To cite this abstract:Ponor I, Eid S, Nwaigwe E. Cardiac Perforation: A Rare Cause of a Bloody Heartache!. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 370. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/cardiac-perforation-a-rare-cause-of-a-bloody-heartache/. Accessed May 24, 2019.