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Case Report
Acta Cardiol Sin 2012;28:53-55
Post-Cardiac Injury Syndrome after Permanent
Pacemaker Implantation
Wei-Che Tsai,1 Ching-Ting Liou,1 Cheng-Chung Cheng,1 Kuo-Sheng Tsai,1,2 Shu-Meng Cheng1 and Wei-Shiang Lin1
The mechanism of post-cardiac injury syndrome (PCIS) was thought to be an autoimmune-mediated process
and can involve the pleura and pericardium. PCIS may result in pleural effusion, pericardial effusion or even
acute pericarditis leading to cardiac tamponade following chest trauma, or other invasive procedures such as
coronary angioplasty or transvenous pacemaker implantation, especially in dual chamber mode with active
atrial fixation leads. Typically, the outcomes of PCIS were good, and most cases were treated conservatively
without surgical intervention, with no mortality case reported. Here, we report on a patient with PCIS after
permanent pacemaker implantation, who was successfully treated with non-steroid anti-inflammatory drugs
(NSAIDs) and colchicine.
Key Words:
Pacemaker · Pericardial effusion · Pericarditis · Pleural effusion
the 2nd, 3rd and 4th day.
Unfortunately, the patient developed shortness of
breath with a low grade fever (37.5 °C) on the 5th day, but
her physical examination revealed no pericardial friction
rub; a follow-up chest x-ray showed increased cardiac silhouette without pacemaker leads protruding into the
pericardium. Leukocytosis with neutrophil predominance
and an elevated level of C-reactive protein (CRP = 7.07
mg/dL) were also noted. The subsequent computed tomography (CT) scan of chest (Figure 1) and echocardiography disclosed a moderate amount of pericardial
effusion without diastolic collapse, and bilateral pleural
effusion with mild partial passive atelectasis in both
lungs. Without invasive therapeutic pericardiocentesis,
her symptoms improved after conservative treatment with
non-steroid anti-inflammatory drugs (NSAIDs), naproxen
750 mg once a day, and colchicine 0.5 mg twice a day.
The subsequent chest x-ray and echocardiography showed
a reduced heart size (Figure 2, left part) and a decreased
amount of pericardial fluid. The patient was discharged
after her symptoms were relieved, and there was no clinical or echocardiographic sign of recurrent pericardial
effusion after a follow-up one month later (Figure 2,
right part).
CASE REPORT
A 78-year-old female had suffered from frequent
dizziness and transient loss of consciousness for three
weeks before admittance. Sick sinus syndrome was confirmed via 24 hours of Holter EKG monitoring, and the patient was treated with permanent pacemaker implantation
(Medtronic Adapta, DDDR mode, active fixation leads, SN
PJN2068017, Minneapolis, MN, USA) with the right ventricular lead screwed towards the septum region, and the
right atrial lead screwed over the anterior wall of the right
atrium. No chest pain was noted after the procedure, however paroxysmal atrial fibrillation (PAF) developed on the
following day and was terminated after intravenous
amiodarone infusion. Afterward, PAF recurred again on
Received: January 31, 2011
Accepted: June 28, 2011
1
Division of Cardiology, Department of Internal Medicine, Tri-Service
General Hospital, National Defense Medical Center; 2Department of
Sports Science, Taipei Physical Education College, Taipei, Taiwan.
Address correspondence and reprint requests to: Dr. Wei-Shiang Lin,
Division of Cardiology, Department of Internal Medicine, Tri-Service
General Hospital, National Defense Medical Center, Tel: 886-2-87923311 ext. 16118; Fax: 886-2-6601-2656; E-mail: wslin545@ms27.
hinet.net
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Acta Cardiol Sin 2012;28:53-55
Wei-Che Tsai et al.
Figure 1. Increased cardiac silhouette and moderate amount of pericardial effusion on 5th day with the right atrial lead screwed at anterior wall
and right ventricular lead screwed toward the septum without evidence of lead protruding into the pericardium.
A
B
C
Figure 2. (A) Resolved gradually 12 days, (B) 1 month and (C) 6 months later.
DISCUSSION
pain (91%) and dyspnea (57%). Additional signs of
PCIS are fever (66%), and pericardial friction rub
(63%), with the most common laboratory findings being
an elevated erythrocyte sedimentation rate (96%) and
leukocytosis (49%).8,9
Greene et al. reported 123 consecutive patients who
received dual-chamber pacemaker insertion with active
atrial fixation bioplar leads, and six patients (4.9%) developed acute symptomatic pericarditis. 10 In these six
patients, the atrial leads were screwed into the lateral or
anterior lateral wall of the right atrium, a location which
is similar to that used in our case. Fortunately, all patients were successfully treated with NSAIDs and had
resolution of symptoms within two weeks. In 2004,
Zeltser et al. conducted a retrospective study in children
and young adults regarding PCIS after permanent pacemaker implantation. In that study, 443 pacemakers (237
epicardial and 206 transvenous) were implanted in 370
patients, and eight (2%) episodes of PCIS (6 epicardial
and 2 transvenous) occurred in seven patients. 11 They
were managed successfully with medical therapy including a NSAID and corticosteroids. The patient’s refrac-
Post cardiac injury syndrome (PCIS) refers to
several terms, including post myocardial infarction syndrome (PMIS), post commissurotomy syndrome (PCS)
and post pericardiotomy syndrome (PPS). It is a common complication after cardiac surgery and the reported
incidence varies from 10% to 50%.1 In 1959, William
Dressler2 first described the pericarditis-like presentation
which developed days to weeks after myocardial infarction, and the autoantigens-related hypersensitivity reaction was considered to be the mechanism. Meanwhile,
Janton et al.3 observed PCS in patients who underwent
surgical intervention for rheumatic mitral stenosis. Again,
Ito et al.4 mentioned PPS occurred in patients who had
received surgical correction of congenital heart disease.
In the years that have followed, several authors reported
that PCIS could be observed after percutaneous coronary
angioplasty,5 radiofrequency catheter ablation6 and pacemaker implantation.7
The clinical manifestations of PCIS are nonspecific,
with the most common symptoms being pleuritic chest
Acta Cardiol Sin 2012;28:53-55
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Post-Cardiac Injury Syndrome
REFERENCES
tory to medical therapy were successfully treated with
pericardiocentesis or surgical creation of a pericardial
window.
Spindler et al.12 reported 10 similar cases in the literature and subsequently added this case into analysis (n =
11, 8 women and 3 men). Most of his subjects (n = 9,
81.8%) received dual-chamber pacemaker implantation,
and active atrial fixation leads were inserted into five
patients (45.4%). PCIS developed between five and 56
days after pacemaker implantation (mean 21.5 days),
and all patients had pericardial effusion identified via
echocardiography and CT scan of the chest. The outcomes of these cases were good and most of them (n = 7,
63.6%) could be treated conservatively without surgical
intervention. Recently, Hsu et al. reported Takotsubo
cardiomyopathy developed after permanent pacemaker
implantation, and could be a potential complication after
pacemaker implantation.13
In conclusion, although the pacemaker implantation
procedure is safe and feasible, some clinical presentations should remind us to be suspicious of PCIS and its
symptoms, especially during dual-chamber pacemaker
insertion with active atrial fixation leads, or when a history of temporary transvenous pacemaker use before
the permanent pacemaker implantation is involved.
These symptoms included shortness of breath, fever, elevated sedimentation rate, and even an unexplained
drop in hemoglobin in the absence of an obvious inflammatory process. If identified early, most patients
can be successfully treated with NSAIDs, colchicine
and/or prednisone, and further surgical intervention
may be avoided.
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