Via Research Recognition Day 2024 VCOM-Carolinas

Clinical Case-Based Reports

From Constipation to Cardiac Complication: An Uncommon Presentation of Myocardial Perforation Nicole Gentile, OMS-III, Fiona Bradshaw, OMS-III, Lynn Campbell, DO, FACOEP, FACEP Edward Via College of Osteopathic Medicine – Carolinas Campus. Spartanburg Regional Medical Center, Church Street Campus. Spartanburg, SC. Background Diagnosis

Treatment & Outcome

Cardiac device implantation is a low-risk procedure and has been increasing in occurrence over the past few decades as implantable cardiac defibrillators (ICDs) play a vital role in maintaining cardiac function. Pacemaker complications are relatively rare with a rate of 3%-7.5 %1,2 . Common acute complications include pneumothorax, lead displacement, and least commonly myocardial perforation. 1 Myocardial perforation, while rare, is important to catch and diagnosis. Acute perforations occur within 24 hours of placement, while subacute perforations occur within the first month 1,2 . As the

Conclusion Treatment: • Chest tube placement: o A right chest tube was placed with 500 mL of bloody output. • Surgery: o The next morning, he underwent a right mini-thoracotomy, exploratory pericardiotomy, and removal of the right atrial lead. o The lead was visualized exiting the pericardium, specifically the free wall of the right atrium, and entering the medial right lobe. o The lead was not replaced at that time due to concern for infection. Outcome: o The patient tolerated the procedure well and was discharged home. Follow-up: o Outpatient follow-up with cardiology for lead replacement. This is an unusual case both in occurrence and presentation. Pacemaker implantation is a low-risk procedure with complication rates between 3 7.5%. Acute complications including pneumothorax, lead displacement, and myocardial perforation are rare, but often life-threatening. Myocardial perforation has an incidence of 0.37-1% and most commonly occurs through the right ventricular apex. If this occurs, it has the highest rate of occurrence during initial pacemaker placement. This patient's lead perforation through the free wall of the right atrium is a rare site for myocardial perforation. ȋͷȌ Typical presenting symptoms of myocardial perforation include symptoms pointing to cardiovascular and pulmonary pathology. Common symptoms include chest pain, dyspnea, syncope, and symptoms pointing to heart failure or cardiac tamponade. This patient lacked any acute symptoms on presentation to the ED that pointed to life-threatening cardiovascular or pulmonary issues. His presenting symptoms of generalized weakness and constipation can point to any number of issues but are not common symptoms of acute myocardial perforation. Clinical Pearls: 1. A recent history of pacemaker placement indicates the need for a CXR to exclude post-procedural complications. 2. Myocardial perforation should be considered in all patients with a pacemaker regardless of time since insertion. 3. Risk factors for myocardial lead perforation include female sex, older age, history of heart failure, right ventricular ICD, and multi-chamber ICD implantation 5 .

Image 1

right atrial wall is much thinner, it is expected to be the most common location of perforation, but most occur through the right ventricular apex 1,2,3 as it is the traditional location of ventricular pacing leads ( Image 1 ).

Case Presentation

Image 2A & 2B: CXR (left) showing small right apical pneumothorax and ICD right ventricular lead outside the cardiac silhouette overlying the right lung base. Right pleural effusion and pneumothorax likely as a result. Compared to CXR (right) taken after ICD placement 5 days prior, confirming good position of cardiac device and leads.

A 70-year-old African American male with a past medical history of hypertension, hyperlipidemia, bilateral carotid artery occlusion, and complete heart block status post percutaneous dual pacemaker placement five days prior presented to the emergency department (ED) by ambulance with complaints of generalized weakness and constipation. He denied any abdominal pain/distension, nausea, vomiting, diarrhea, urinary complaints, chest pain, shortness of breath, or dizziness. Vital signs included BP 137/71 mmHg, HR 86, RR 19, Temp 97.8 ºF, pulse ox of 94% on room air. On exam, he was ill-appearing, but in no acute distress with a pacemaker present In chest wall. An electrocardiogram (EKG) and chest x-ray (CXR) were orders, labs were drawn, and the pacemaker was interrogated. • EKG showed sinus rhythm with occasional premature ventricular complexes with no evidence of ST-segment elevation/depression. • CXR ( Image 2A ) showed a small apical pneumothorax with the ICD right ventricular lead outside the cardiac silhouette and was compared to the CXR taken after pacemaker placement ( Image 2B ), which showed good lead position without evidence of perforation. • Labs were significant for an elevated white blood count of 11.5 k/uL,but were otherwise unremarkable. • A computer tomography pulmonary angiogram (CTPA) ( Image 3 ) confirmed that the right atrial pacemaker lead was perforating through the lateral right atrial appendage into the right hemithorax resulting in a moderate right pleural effusion. • Pacemaker interrogation showed the ventricular lead functioning appropriately, but the atrial lead had “fallen” and was only paced 2% of the time. No episodes of ventricular tachycardia or atrial fibrillation were noted. No shocks delivered.

Typical Signs & Symptoms 4

Image 3: CTPA shows moderate right pneumothorax and moderate right pleural effusion increased in density possibly hemorrhagic fluid related to the right atrial lead perforating through the lateral right atrial appendage into the right hemithorax. Pneumomediastinum is present.

• Chest pain • Dyspnea • Syncope (secondary to hypotension) • Hiccups • Loss of consciousness (due to failure to pace) • Symptoms of heart failure – orthopnea, pedal edema, fatigue • Symptoms of cardiac tamponade – tachypnea, tachycardia, jugular vein distension

Definitive Diagnosis: Ͳ Perforation of the right atrium by the right atrial pacemaker lead resulting in right hemopneumothorax requiring immediate intervention

Special thanks to Spartanburg Regional, Dr. Campbell and Dr. Hagel, the ED physician who cared and managed the patient initial presentation and management. Thank you to our patient for allowing us to learn from him and share his unique presentation.

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2024 Research Recognition Day