Cough-induced sudden acute chest pain and massive left hemothorax soon after pacemaker implantation

A 74-year-old man who recently undergone a definitive pacemaker implantation with an apical septal active lead fixation presented to the emergency department because of a new-onset acute chest pain that began soon after cough episodes. Pacemaker interrogation reported an increased bipolar pacing threshold (3.25 V at 1 ms). Contrast-enhanced chest CT scan and percutaneous angiography revealed the sequential perforation of the right ventricular apex and the left internal mammary artery by the ventricular pacemaker lead. Successful percutaneous embolization of the LIMA, blood transfusion and thoracentesis were then performed, and the patient subsequently underwent a percutaneous ventricular lead extraction followed by re-implantation, with an uneventful follow-up after 2 years. This unique case report highlights a potential rare complication of the active fixation of the ventricular lead at the apical interventricular septum and should lead the clinicians to keep in mind right ventricular perforation, even without cardiac tamponade, in patients presenting for cardio-pulmonary symptoms soon after pacemaker implantation.