Massive Tension Hemothorax After Pacemaker Implantation

Abstract

A case of an 85-year-old male on apixaban and clopidogrel undergoing pacemaker implantation is described. After procedure he developed unilateral tension hemothorax and required emergent drainage and exploratory thoracotomy. No vascular, cardiac, or pulmonary source was identified. After multidisciplinary discussions, it was speculated that spontaneous intercostal vessel rupture due to forceful coughing and elevated blood pressure during the procedure was the most likely cause of bleeding.

Keywords: cardiac pacemaker; cardiology devices; critical hemorrhagic shock; intercostal vessel rupture; tension hemothorax.

Figure 1. Left: Initial chest X-ray immediately after procedure. The film shows good lead position and mild, bilateral lung field infiltrates with possible small left-sided pleural effusion. Right: Emergent repeat chest X-ray showing newly appeared complete opacification of the left hemithorax (red arrow) with left lung collapse. Rightward mediastinal shift is present, as evidenced by the right-sided carina (yellow arrow).

Figure 2. Left: Echocardiogram four months prior to procedure with chronic pericardial effusion. Right: Emergent post-procedure echocardiogram showing a new pleural effusion and a stable, small pericardial effusion without evidence of increased filling pressures.

Figure 3. Left: Pre-procedure venogram with patency of the central vasculature. Right: Post-procedure, invasive catheter selective left subclavian venogram showed the left subclavian and axillary veins and their respective branches without evidence of contrast extravasation.

Figure 4. Contrast-enhanced computed tomography showed small pleural hemorrhage and third and fourth rib fractures (white arrow).