Background: Pneumothorax is an important early complication of cardiac pacemaker implantation however little is known about the modern incidence and outcomes. Current guidelines do not distinguish between causes of iatrogenic pneumothorax and so procedure specific data is needed to help guide cardiologists and respiratory clinicians alike.
Method: Retrospective analysis of patients who developed a pneumothorax as a result of cardiac pacing from January 2015 to September 2019 was undertaken. Cases were identified from data linkage of the cardiac devices database and pneumothorax medical code. Clinical and procedural characteristics were recorded and outcomes of interest included incidence of pneumothorax and subsequent management outcomes.
Results: During the study period, 6643 cardiac devices were implanted at our large tertiary cardiothoracic centre. Pneumothorax occurred in 43/6643 (0.65%). Those suffering from pneumothorax had an average age of 74.2 years, 24/43 (56%) were male, 9/43 (20.9%) had previously known lung disease. Vascular access was obtained via subclavian vein 25/43, axillary 16/43, cephalic 1/43, revision 1/43.  Of the devices inserted 18/43 were pacemakers, 12/43 CRT, 13/43 were ICD. First operator was a consultant in 20/43 cases and registrar or fellow in 23/43. Conservative management was adopted in 34/43 (79.1%), with chest drain inserted in the remainder. Only 8 patients managed conservatively required subsequent pleural intervention, giving a success rate of 76.5% for primary conservative management. Mean ±SD length of stay was 3.9±6.7 for primary conservative management and 7.1±6.1 for primary chest drain insertion. The respiratory specialists (5/9) or thoracic surgical specialists (4/9) inserted all chest drains where that was opted as the primary management strategy. For those managed initially conservatively the cardiologists managed this alone 9/34, advise was sought from the thoracic surgical specialists 2/34, telephone advice from the respiratory specialists 7/34 and respiratory specialist review 16/34. Respiratory specialists were involved with all 8 patients initially managed conservatively who subsequently went on to have a chest drain inserted.
Discussion: Pneumothorax incidence is rare but not negligible following cardiac pacemaker implantation. The majority of cases can be safely managed with conservative management. Where chest drain insertion is indicated, specialist advice from respiratory or thoracic surgical team should be obtained.
