Right Atrial Perforation With Pericardial Effusion and Visceral Pericardial Flap Observed During Pacemaker Implantation: An Echocardiographic Case Report

Figure 1. Baseline Electrocardiogram A 12-lead electrocardiogram showing sinus rhythm with a normal PR interval and a widened QRS complex. A complete right bundle branch block and left-axis deviation are present, findings consistent with left anterior fascicular block. No evidence of acute ischemia.

Figure 2. Twenty-Four-Hour Holter Recording Simultaneous three-lead tracing (leads II, V1, and V5) showing baseline sinus rhythm interrupted by prolonged sinus arrest episodes, with pauses exceeding 3.5 seconds and no escape activity - findings consistent with severe sinus node dysfunction. The QRS complexes display morphology consistent with complete right bundle branch block.

Figure 3. Post-implantation Electrocardiogram Regular rhythm at 82 bpm with sinus P waves preceding each QRS complex, indicating effective atrial sensing. Pacemaker spikes precede each QRS, consistent with dual-chamber pacing in DDD mode. The QRS complex is widened with morphology of an artificial left bundle branch block and an electrical axis of approximately +30°, suggestive of septal right ventricular pacing.

Figure 4. Posteroanterior and Lateral Chest Radiographs Chest radiographs (posteroanterior and lateral views) showing the pacemaker generator in the left subclavicular position with leads correctly positioned in the right heart chambers - the atrial lead anchored to the anterolateral wall of the right atrium and the ventricular lead directed toward the septal or apical region of the right ventricle. The cardiac silhouette appears mildly enlarged, with elongation and calcification of the aortic arch, increased bronchovascular markings, and a subtle basal interstitial pattern. No evidence of pneumothorax or generator displacement (arrows indicate the anchoring site of the right atrial lead).

Figure 5. Non-contrast Chest Computed Tomography Axial (left) and sagittal (right) computed tomography images demonstrate a high-attenuation pericardial effusion consistent with mild hemopericardium (arrow) and focal mural heterogeneity along the anterior right atrial wall (arrow), suggestive of a contained microhematoma at the lead fixation site. Additional findings include a small-to-moderate right pleural effusion, diffuse coronary and aortic calcifications, and subtle basal interstitial thickening consistent with mild interstitial lung disease.

Figure 6. Clinical Timeline of Event Chronological sequence summarizing the patient’s clinical course, beginning with symptomatic sinus node dysfunction and Holter documentation of sinus pauses, followed by dual-chamber pacemaker implantation and a transient post-procedural hypotensive episode. Periprocedural echocardiography revealed a mild pericardial effusion with a mobile visceral pericardial flap, and a 24-hour CT scan confirmed a contained right atrial microhematoma with mild hemopericardium and a small right pleural effusion. A follow-up echocardiogram on day 8 demonstrated a stable mild effusion and preserved ventricular function, supporting successful conservative management and discharge.