Right haemothorax secondary to pulmonary vein laceration following left-sided pacemaker implantation: a case report

Background: Lead perforation is a rare but potentially fatal complication of cardiac device implantation. Atrial lead perforations, though less common than ventricular ones, can have severe consequences, especially in elderly patients with underlying structural heart disease. Case summary: An 83-year-old male with amyloid and valvular cardiomyopathy underwent dual-chamber pacemaker implantation for third-degree atrioventricular block following transcatheter aortic valve implantation. The active-fixation atrial lead was positioned on the right atrial free wall. Six hours post-implantation, the patient developed haemodynamic instability. Echocardiography revealed a small pericardial effusion, while pacemaker interrogation showed an increased atrial pacing threshold. Chest imaging demonstrated a moderate right haemothorax. Initially, conservative management was recommended. However, the patient's condition deteriorated, progressing to cardiac arrest requiring brief cardiopulmonary resuscitation. Emergency sternotomy revealed a large right haemothorax and laceration of the right upper pulmonary vein in contact with the atrial lead screw. The laceration was repaired, and the atrial lead was repositioned. The patient recovered well and was discharged 5 days after surgery. Discussion: Lead perforation is an uncommon but potentially severe complication of pacemaker implantation, with an incidence of 0.5-1% of cases. Several risk factors have been identified, including advanced age, low body mass index, atrial remodelling, and lateral lead placement. In this case, the atrial lead perforation extended from the atrial wall to the right superior pulmonary vein. This case underscores the potential risks associated with lateral lead positioning in geriatric patients and emphasizes the necessity for meticulous lead placement and vigilant post-implantation monitoring to mitigate complications.