A case of cardiac perforation

A 58 years old man with chest pain and dyspnea was admitted to Emergency department. His medical history was characterized just by an implantation of cardiac pacemaker (PMK) 15 days before the admission to treat a bradyarhythmia. Patient was diaphoretic, tachypnoic, mental status was preserved. Physical examination revealed tachycardia, soft heart sounds, murmure abolition in the left hemithorax. Blood pressure was 130/80 mmHg, oxymetry was 95% in o2 4l/min, heart rate was 140 bpm. EKG showed sinus tachycardia. Point of care ultrasound identified a massive left pleural effusion, a normal A profile at right lung, a normal inferior vena cava diameter in expiration with a collapsibility index of 50% and a pericardial effusion with a floating echogenic image, without cardiac tamponade (Fig 1). We administer metoprolol 5 mg i.v. to reduce heart rate, morphine 2 mg i.v., oxygen by venture mask 60%. We performed a thorax angio-CT scan that confirmed migration of PMK lead tip in the pericardium sac through the right ventricular wall, conditioning emopericardium and emothorax. Patient was admitted to cardiothoracic surgery (Fig 2). A two-step surgical strategy was chosen. In a first step, by an open surgery approach, the migrant ventricular lead tip was cut while the rest of the lead was left in intracardiac position, the perforation of RV wall was repaired and the hemopericardium and hemothorax were evacuated, with an improvement of the hemodynamic state of the patient. In a second step, two days later, the remaining portion of the PMK ventricular lead was removed transvenously and a new PMK was implanted. The patients was discharged five days later.