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Case Report Defibrillator Devices Bilateral Pneumothorax Post Insertion of Intracardiac Defibrillator, a Rare Condition, Risk Factors and Prevention Maryam Ayati, Syamkumar Divakara Menon, Carlos A Morillo, Jeffrey Healey and Stuart J Connolly Arrhythmia & Pacing Service, Hamilton Health Sciences, McMaster University, Hamilton, Canada Abstract The implantation cardiac rhythm management devices is rising annually. The two known common complications of these devices, infection and pneumothorax, occur in 1.2% and 0.6% of patients, respectively. Pneumothorax is usually seen in the ipsilateral part of implantation however in some rare cases this will be seen in the contralateral part. Despite using cephalic vein cutdown or venogram assisted puncture of axillary vein to reduce this complication, pneumothorax remains the one of the most morbid complications post implant. In this article a rare case of bilateral pneumothorax will be presented and discussed. Keywords Bilateral pneumothorax, implantable cardiac devices, cephalic vein cutdown Disclosure: Maryam Ayati, Syamkumar Divakara Menon, Carlos A Morillo, Jeffrey Healey and Stuart J Connolly have nothing to declare in relation to this article. No funding was received for the publication of this article. Compliance with Ethics Guidelines: All procedures were followed in accordance with the responsible committee on human experimentation and with the Helsinki Declaration of 1975 and subsequent revisions, and informed consent was received from the patient involved in this case study. Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any non-commercial use, distribution, adaptation and reproduction provided the original author(s) and source are given appropriate credit. Received: 18 February 2016 Accepted: 3 March 2016 Citation: European Journal of Arrhythmia & Electrophysiology, 2016;2(1):40–1 Correspondence: Maryam Ayati, Hamilton Health Sciences, McMaster University, 1200 Main St. West, Hamilton, Canada, L8N 3Z5. E:aiaty50@gmail.com The use of implantable cardiac rhythm management (CRM) devices has been on the rise worldwide with approximately one million implant per year. 1 The two common complications of CRM device implants are infection and pneumothorax with the prevalence of 1.2% and 0.6% respectively. 2 Despite the use of techniques to reduce pneumothorax, such as cephalic vein cutdown, venogram assisted puncture of axillary vein, and use of ultrasound guided vascular access, this complication still occurs in patients undergoing CRM implants. Pneumothorax typically occurs ipsilateral to the site of vascular access; however, there is a report of pneumothorax occurring on the contralateral side of the puncture 3 or even bilaterally. Here we present a case with history of coronary artery bypass graft (CABG) surgery who developed bilateral pneumothorax following implantable cardioverter defibrillator (ICD) implantation. Case discussion A 74-year-old male patient presented with a sudden onset exertional dyspnea and signs and symptoms of heart failure. Twelve channel electrocardiogram (ECG) confirmed monomorphic ventricular tachycardia. In addition, transthoracic echocardiography showed a large ventricular septal defect with left to right shunt, due to myocardial rupture of inferoseptal wall. Subsequent coronary angiogram demonstrated chronic total occlusion (CTO) of both the right coronary artery and circumflex coronary artery and also 50% stenosis in left anterior descending artery. The patient was operated the same day and had an uneventful follow up post CABG and ventricular septal defect repair operation. 40 A single chamber ICD was implanted for secondary prevention. Vascular access was obtained by venogram assisted axillary vein puncture, and implantation procedure was completed uneventfully. Post procedure chest X-ray showed large bilateral pneumothorax, which was larger in the right side (Figure 1). The patient initially underwent an uneventful bilateral pleural drainage with pigtail which was unable to expand the lung adequately. He then underwent a bilateral chest tube which was followed by a third chest tube insertion in the middle of his chest due to lack of adequate lung expansion. A chest computed tomography (CT) scan was conducted to elucidate the mechanism of pneumothorax and any underlying pulmonary pathologies. This revealed communication between the right and left pleural spaces through the anterior mediastinum (Figure 2), which is not an uncommon finding after cardiac surgeries involving midline sternotomies. After five days, all tubes were removed, the chest X-ray showed full expansion of both lungs and the patient was discharged home. Discussion Although ipsilateral pneumothorax is the most common complication of subclavian puncture with the incidence of 0.6–7.5%, 4 iatrogenic bilateral pneumothorax post median sternotomy has been previously reported. This issue has been first reported by Schorlemmer et al. in 1984 in a patient with previous median sternotomy who needed subclavian TOU C H ME D ICA L ME D IA