Abstract Introduction About 1-2% of pacemaker implantation cases are complicated by pneumothorax due to needle injury of the pleura in the subclavian vein or atrial lead perforation. In humans, the right and left pleural cavities are completely separated and independent. Thus, bilateral pneumothoraces, resulting from iatrogenic procedures or traumas, are a rare clinical occurrence There are only a handful of cases relating this seldom described clinical phenomenon to Buffalo Chest Syndrome, which refers to simultaneous bilateral pneumothorax secondary to an unusual interpleural connection. Case Presentation A 92-year-old woman with a history of chronic atrial fibrillation on anticoagulation presented to the emergency department after a syncopal episode and was found to have complete heart block. She underwent dual-chamber pacemaker implantation via the left subclavian approach, with an unremarkable intraoperative and immediate postoperative course. On postoperative day 1, routine anteroposterior and lateral chest radiographs obtained to confirm leads position revealed an iatrogenic moderate-sized left pneumothorax. The pneumothorax size subsequently enlarged on follow-up imaging, necessitating placement of a bedside chest tube, which resulted in marked radiographic improvement. On day 2, the chest tube was placed on an underwater seal after radiologic resolution of the left pneumothorax. Following a clamping trial on day 3, recurrence of the left pneumothorax occurred, accompanied by the unexpected development of a new contralateral right pneumothorax. The left-sided chest tube was immediately reconnected to negative pressure suction. A thoracic surgery consultation was obtained to assess potential interpleural communication. However, contrast-enhanced computed tomography showed no evidence of pleural connection. By postoperative day 4, repeat imaging confirmed resolution of the bilateral pneumothoraces, allowing transition of the chest tube back to an underwater seal. The tube was eventually removed after a successful clamping trial on day 5, and the patient was discharged safely to a skilled nursing facility on day 6. Discussion Simultaneous bilateral pneumothoraces following a unilateral procedure are exceedingly rare. Proposed mechanisms include subclinical barotrauma or a pre-existing congenital or acquired pleuropleural fenestration. This case underscores the importance of vigilant postoperative monitoring following pacemaker implantation. Even unilateral procedures can precipitate bilateral pneumothoraces, highlighting the need to consider contralateral involvement when patients exhibit unexpected respiratory symptoms or radiographic changes. This abstract is funded by: None
Dao et al. (Fri,) studied this question.