Pneumopericardium due to atrial lead perforation: BMJ case r
Permanent pacemaker (PPM) implantation is an increasingly common procedure with complication rate estimated between 3% and 6%. Cardiac perforation by pacemaker lead(s) is rare, but a previous study has shown that it is probably an underdiagnosed complication.

The authors present a case of a patient who presented 5 days after PPM insertion with new-onset pleuritic chest pain. She had a normal chest X-ray (CXR), and acceptable pacing checks. However, a CT scan of the chest showed pneumopericardium and pneumothorax secondary to atrial lead perforation. The pain only settled by replacing the atrial lead. A repeat chest CT scan a few months later showed complete resolution of the pneumopericardium and pneumothorax.

The authors believe that cardiac perforation can be easily missed if associated with normal CXR and acceptable pacing parameters. Unexplained chest pain following PPM insertion might be the only clue for such complication, although it might not always be present.

Learning points
• A careful approach should be considered in patients with new chest pain following a cardiac device insertion including CT imaging of the chest. Chest X-ray and pacing checks might be misleadingly normal.

• Slight alteration in pacing checks can sometimes be useful indicator of certain pathologies. High pacing threshold has been particularly linked with atrial lead perforation in previous cases. Special attention should, therefore, be paid to such subtle changes especially in the context of unexplained symptoms.

Read in detail about the case here: