Bilateral Pneumothorax after pacemaker placement

Case Report:
Bilateral Pneumothorax after Pacemaker Placement
Student’s NameDepartment of Internal medicine, Division of Pulmonary and Critical care, Good Samaritan hospital, Wright State University, Dayton, Ohio, USA.InstitutionStudent’s Contact Info.Professor’s Name
Wd Count: 846
Abstract
Bilateral pneumothoraces after unilateral subclavian vein cannulation, as a complication, is a rare occurrence. It is usually associated with an intrapleural communication which can be congenital or formed following cardiothoracic and mediastinal surgeries, or trauma. The term Buffalo chest was used to define a single chest cavity with no anatomic separation of the two hemithoraces. It is called Buffalo chest because this unique chest anatomy of the American buffalo, or Bison, helped hunters to kill them by a single arrow to the chest which was enough to let air in to collapse both lungs. However, the Pleural cavities in humans are separated entirely from each other.
We described an 83-year-old female without any known lung disease, underwent Dual chamber permanent pacemaker placement for symptomatic intermittent complete heart block and paroxysmal atrial fibrillation, using the left subclavian vein as a site of venous entry, who developed bilateral pneumothorax after the procedure. She had no prior history of cardiothoracic surgery or Trauma. The Bilateral Pneumothorax was utterly resolved after single left-sided Thoracostomy tube placement suggesting the patient had “Buffalo chest.
Keywords: Pneumothorax, Buffalo chest, Pacemaker.

Table of Contents
TOC o “1-3” h z u Abstract PAGEREF _Toc506667739 h 2Introduction PAGEREF _Toc506667740 h 4Case Report PAGEREF _Toc506667741 h 4Discussion PAGEREF _Toc506667742 h 6REFERENCES PAGEREF _Toc506667743 h 8
IntroductionBilateral pneumothorax as a complication after unilateral subclavian central venous line placement is an uncommon occurrence. This report is a case of bilateral pneumothorax after pacemaker placement using the left subclavian vein as an entry site in a patient without prior Pulmonary disease, Chest surgery or trauma, which resolved after single left-sided thoracostomy tube placement suggesting “Buffalo chest”(1).
In efforts to exclude the presence of asymptomatic pneumothorax after central vein cannulation of subclavian or internal jugular vein, a chest X-ray should be obtained within 4 hours after the procedure as a delayed radiographic evidence of pneumothorax can occur (2).
Case ReportAn 83-year-old African American female with a history of symptomatic intermittent complete heart block, paroxysmal atrial fibrillation, hypertension, and carotid artery disease with no history of prior cardiothoracic surgery, underwent Dual chamber permanent pacemaker placement using the left subclavian vein as an entry site. Chest X-ray was done before the procedure showed no evidence of pneumothorax. The left subclavian vein was cannulated without difficulty, and the atrial and ventricular leads were inserted, advanced and secured under Fluoroscopy with good pacing and sensing. No difficulties were encountered during leads introduction. Fluoroscopy confirmed correct leads placement. There was no attempt of using the right subclavian vein cannulation during the procedure. Chest X-ray was done before the procedure, and it turns out to be normal. The introducer needle did not cross the midline, and the left subclavian vein was cannulated easily from the first attempt. During and after the procedure no pneumothorax was identified on fluoroscopy and the patient denied dyspnea and chest pain during and directly after the procedure. She was admitted to the hospital overnight for cardiac monitoring. The next morning she developed dyspnea, and on physical exam she had diminished breath sounds bilateral. Chest X-ray showed a 35% pneumothorax on the left side and 20% pneumothorax on the right (Image 1). CT chest did not show any evidence of atrial leads perforation and Echocardiogram was performed which showed no pericardial effusion or tamponade.
A left-sided chest tube was then placed, and repeat chest X-Ray showed complete resolution of both pneumothoraces after a few days with a chest tube to suction. The chest tube was eventually removed. Chest X-Ray after removal of chest tube showed complete resolution of both left and right pneumothoraces. We suspect the patient had a congenital “buffalo chest.”
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Image 1
Image 1
DiscussionUnilateral pneumothorax development can be a complication of pacemaker placement, central venous catheter insertion and various cardiothoracic surgeries and Trauma. Contralateral pneumothorax after pacemaker placement was also reported before and most cases are due to atrial lead perforation which can be detected by CT chest (5). However, bilateral pneumothoraces is a sporadic occurrence after unilateral central venous cannulation. The potential causes of bilateral pneumothoraces after a unilateral pneumothorax from subclavian venous cannulation procedure includes- the preexisting pneumothorax on the contralateral side and a possible puncture of the contralateral pleura or pulmonary bulla. The introducer needle causes the puncture during subclavian cannulation, if crossed midline, or by atrial lead perforation2 which are all ruled out in our patient. The existence of inter pleural communication due to prior cardiothoracic surgery or Trauma is another suggested explanation. Pneumothorax after subclavian vein access may be detected during a procedure (acute) by Fluoroscopy or delayed (subacute) up to 48 hours after the procedure. The existence of iatrogenic inter pleural communication is usually seen in patients following cardiothoracic surgery such as thymectomy, lung transplant (7), mediastinal surgery (4), or even a traumatic event. Awareness of the possibility of this unusual pleural communications is important in a patient with prior sternotomy when subclavian, internal Jugular vein catheterization or lung biopsy (6) is planned to close monitoring the patient for any respiratory distress during and after the procedure suggesting bilateral pneumothorax with potential for tension pneumothoraces(8).
The communication can also be congenital. The diagnosis of “Buffalo chest” can be made by complete resolution of bilateral pneumothorax after a single chest tube is placed.
 
REFERENCES
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Gilbert R. Schorlemmer, MD., Roger K. Khouri, MD., Gordon F.Murray, MD., George Johnson, Jr, MD,: Bilateral Pneumothoraces secondary to iatrogenic Buffalo chest. An unusual complication of Median sternotomy and subclavian vein catheterization. Ann. SurgMarch 1984, Vol 199. No 3, page 372-374.