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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:email@example.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
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
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
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
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