Case Presentation: 77 year old male with history of complete heart block with permanent pacemaker placement and recent diagnosis of nonvalvular atrial fibrillation on apixaban presented to emergency room with chief complaint of abdominal pain and dyspnea on exertion. The complete blood count, electrolyte panel, and serum creatinine were unremarkable. The initial troponin was elevated and EKG showed sinus tachycardia. TTE showed circumferential pericardial effusion with findings concerning for tamponade. Cardiology was consulted and emergent pericardiocentesis was performed. 560 milliliters of hemorrhagic fluid was drained from the effusion. A repeat TTE showed no pericardial effusion after drainage. Gram stain, bacterial, fungal, and mycobacterial cultures on pericardial fluid showed no growth. Cytology was negative for malignancy and serum TSH was normal. After ruling out hypothyroidism, malignancy, and infectious etiologies, the patient’s cardiologist was noted to have adjusted pacemaker leads 2 weeks prior to admission. It was determined that the pericardial effusion was most likely iatrogenic due to microperforation of the right ventricle during pacemaker lead adjustment, with bleeding exacerbated by apixaban use.
Discussion: Pericardial effusions have a wide range of etiologies including infection, inflammation, and malignancy. Right ventricular perforation is an uncommon cause of pericardial effusion, occurring in 0.1-0.8% of pacemaker placements. Risk factors for ventricular perforation include the use of active fixation leads compared to passive fixation leads, low volume operators (<50 annual cases), female gender, age greater than 75 years, BMI less than 25, chronic lung disease, and history of coronary intervention. Symptoms can range from asymptomatic to life-threatening and include chest pain, syncope, abdominal pain, and dyspnea. In this instance, due to tamponade, an emergent pericardiocentesis was performed; however, lead extraction was not deemed necessary during this admission. The necessity of lead extraction, and the optimal means of extraction, whether percutaneous or surgical, remains a matter of controversy.
Conclusions: Cardiac perforation is an extremely rare etiology of pericardial effusion; however, it is associated with significant morbidity and mortality.