Contralateral Pneumothorax after the Implantation of a Dual Chamber Pacemaker

An 85-year-old male presented to the primary care clinic with a one-month history of excessive fatigue and one episode of almost fainting.An electrocardiogram showed Mobitz II second degree heart block with a pulse rate of 36 beats per minute.He was admitted and cardiology was consulted for further work-up and management.His past medical history was significant for diabetes mellitus, hypertension, hyperlipidemia, hypothyroidism, and peripheral vascular disease.Initial laboratory tests showed a normal thyroid profile, complete blood count, liver panel, and renal function panels.His troponin was <0.04 u/dl.With no reversible causes of heart block identifiable, he was scheduled for a permanent pacemaker insertion.He had a dual chamber Medtronic permanent pacemaker placed and remained admitted for overnight observation.The patient complained of substernal chest pain the next day but no shortness of breath.A CT scan showed a pacemaker lead perforating the right atrial myocardium causing right pneumothorax and slight mediastinal shift to the left (Figures 1 and 2).Interrogation of the pacemaker revealed the atrial lead was not capturing and had high impedance.The pacemaker lead was pulled and repositioned in a different location in the right atrium.The patient had a chest tube with underwater seal drainage with resolution of pneumothorax.9