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CASE REPORT
Year : 2021 | Volume
: 24
| Issue : 3 | Page : 443-445
Hemoptysis and massive focal alveolar hemorrhage after successful biventricular pacemaker implantation
M Bankir1, AS Koc2, FF Gorgulu2, HE Sumbul1, M Koc3
1 Department of Internal Medicine, University of Health Sciences - Adana Health Practice and Research Center, Adana, Turkey
2 Department of Radiology, University of Health Sciences - Adana Health Practice and Research Center, Adana, Turkey
3 Department of Cardiology, University of Health Sciences - Adana Health Practice and Research Center, Adana, Turkey
Correspondence Address:
Dr. A S Koc
Department of Cardiology, University of Health Sciences - Adana Health Practice and Research Center, Dr. Mithat Özsan Bulvari Kisla Mah. 4522 Sok. No: 1 Yüregir, Adana
Turkey
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/njcp.njcp_650_18
Abstract
During and after cardiac resynchronization therapy (CRT) implantation, many adverse events may occur. We present an interesting and important patient with hemoptysis and massive focal alveolar hemorrhage in a patient after a successful CRT implantation. CRT implantation was completed without any problems. In the follow-up, complaints of cough and hemoptysis began 1 h after the procedure. On the PA chest X-ray, a ground glass image was found in the left upper zone. Thorax CT revealed focal alveolar hemorrhage in the left upper lobe anterior segmental lung parenchyma. The patient was followed up with medical treatment and discharged in good health.
Keywords: Cardiac resynchronization therapy, focal alveolar hemorrhage, hemoptysis
Introduction 
Cardiac pacemaker implantation is performed by subclavian or axillary vein punction. Complications such as pneumothorax and haemothorax due to subclavian or axillary vein punction, lung laceration due to lung parenchyma puncture, recurrent arterial puncture, air embolism, arteriovenous fistula, thoracic duct injury, and brachial plexus injury may occur when performing implantation, even with the most experienced cardiologists. At least three separate punctures needed for a patient undergoing cardiac resynchronization therapy (CRT). Therefore, puncture-related complications are more frequently expected in these patients. In addition, Patients who are undergoing cardiac resynchronization therapy (CRT) implantation have higher incidence of advanced heart failure (HF), lower ejection fraction (EF), advanced age and other comorbid conditions, and therefore complications associated with puncture are more dramatic in these patients. Therefore, excessive caution is required. Pulmonary or alveolar hemorrhage is very rare during pacemaker implantation and limited numbers of cases are presented in the literature.[1],[2],[3] We present an interesting and important patient with hemoptysis and massive alveolar hemorrhage after a successful CRT implantation procedure. We report a case of hemoptysis and massive alveolar hemorrhage after a successful CRT implantation.
Case Report A 75-year-old female patient who was followed with ischemic dilated cardiomyopathy at an external center was admitted to the Arrhythmia outpatient clinic for CRT implantation. The necessary preparations before the procedure were completed and the patient was taken into procedure after having information about the complications of the procedure. Left pectoral area was prepared for pacemaker implantation. The procedure was performed by 2 cardiologists. Three subclavian vein punctures were performed without any complications using the roadmap system. The right ventricle, LV (coronary sinus), and right atrial leads were successfully inserted, respectively. The operation was completed successfully. The patient had no complaints of dyspnea, cough, or hemoptysis during the procedure. The patient was taken to the Arrhythmia service for follow-up.
At the first hour of the follow-up, the patient complained of cough and hemoptysis. The PA chest X-ray showed patchy appearance of ground glass image in the upper zone of the left lung [Figure 1]. Contrast-enhanced CT was performed immediately. CT revealed hyper-dense airspace consolidation compatible with focal alveolar hemorrhage in the left upper lobe anterior segment parenchyma [Figure 2] and [Figure 3]. All these findings were thought to be compatible with massive local intraalveolar hemorrhage. In the clinical follow-up, there was no deterioration in hemodynamics and oxygen saturations. Then, the patient was followed conservatively. The patient's complaint of hemoptysis continued for 2 days after the operation and then disappeared. Intraalveolar hemorrhage has found to be resorbed in following PA chest radiographs and the clinically recovered patient was discharged with appropriate medical treatment.
Figure 1: The postoperative PA chest X-ray showed a patchy appearance of ground glass image in the upper zone of the left lung. There were no findings consistent with pneumothorax and hemothorax
Figure 2: Coronal image of contrast-enhanced computerized tomography showed hyperdense airspace consolidation areas and small atelectatic areas consistent with focal alveolar hemorrhage in the left lung upper lobe parenchyma. There were no findings consistent with pneumothorax and hemothorax
Figure 3: Axial image of contrast-enhanced computerized tomography revealed hyperdense airspace consolidation areas and small atelectatic areas consistent with focal alveolar hemorrhage in the left lung upper lobe anterior segment parenchyma Discussion Complications of alveolar hemorrhage are not included in the current pacemaker guidelines and are one of the rare complications in which we do not have any knowledge about their follow-up and treatment.[4] This a complication has a frequency of <0.1% and happens to me first time in my case series that includes >5000 patients.[5] Pulmonary parenchymal laceration and associated hemoptysis, alveolar or parenchymal hemorrhage are very rare in pacemaker implants after deeper puncture of the subclavian vein than in normal, and only a limited number of case reports are presented in the literature.[1],[2],[3] In this case report, for the first time in our clinic, we present a case of a massive alveolar hemorrhagic disease that occurred after CRT-D implantation and limited itself with clinical follow-ups. Major complications associated with CRT-D implantation are higher than traditional pacemaker implantation.[4] The most important causes of peri-procedural complications in CRT-D patients were patients having elderly subjects, advanced stage HF, lower LV-EF, frequency of co-morbid diseases, the requirement of coronary sinus cannulation, and the requirement of at least 3 times punctures for subclavian or axillary vein.[6],[7],[8] Vetta F. et al.[7] reported an increased risk of pneumothorax and hemothorax compared to younger subjects in elderly individuals undergoing CRT-D implantation. This data is certainly closely related to the comorbidities of elderly patients, finding a fertile ground in the frequent ribcage deformities evident in this age group. The systematic use of the subclavian or axillary vein puncture leads to an increased risk directly related to the number of punctures performed per procedure.[8] This is why the systematic use of the cephalic vein for as many leads as possible is recommended especially in the very elderly patient.[7],[8] To reduce the risk of procedural complications, the Subclavian Vein Ultrasound-Guided Cannulation technique may be useful, especially in the elderly patient.[9] However, complications associated with subclavian vein puncture may even occur in most experienced operators. For these reasons, in patients undergoing CRT-D implantation and especially in older age (i) Subclavian Vein Ultrasound-Guided Cannulation technique, (ii) guidewire technique from cephalic and basilic veins, and (iii) venography technique, the complication associated with the procedure can be reduced. some operators still recommend venography or guide wire technique from cephalic and basilic veins.[1]
In the case reported by Yelgec et al.[2], it was reported that CRT-D was planned but the patient could not be operated because general condition of the patient was deteriorated after the second puncture. One of the most important problems in this case is the prosthetic mitral valve and oral anticoagulant use (INR = 1.7). Another case occurred with an experienced operator during conventional VDD pacemaker implantation and the procedure was completed successfully. The most important feature of this patient is that the patient is not accompanied by a serious comorbid disease except being 80 years old. Therefore, the findings of this case were stabilized within 72 h. Alveolar hemorrhage and its associated haemoptysis clinic is not only occurs during pacemaker implantation, but also in subclavian vein catheterization.[10] In addition, this complication is not only due to subclavian vein puncture but also can be seen in the axillary vein puncture, which is farther than the pulmonary parenchyma.[3] In our case, unlike the previous cases, hemoptysis was not seen during the procedure, but after the procedure. Therefore, the CRT procedure was performed successfully. Also, as the patient's bleeding was massive, the diagnosis of alveolar hemorrhage was clearly demonstrated by CT, in addition to PA chest radiography. Despite the massive bleeding, hemodynamics, HF and oxygenation were stable, and the patient was followed up with supportive care under observation and was discharged in good health.
In conclusion, as a result of the limited number of cases in the literature and results obtained in our case, parenchyma puncture and associated hemoptysis and alveolar hemorrhage are rare while performing pacemaker and especially CRT-D implantation, but are an important problem. Although hemoptysis and related findings due to pulmonary parenchymal puncture occur during the procedure, it may also occur in the late post-puncture period, indicating that post-operative follow-up is very important. For this reason, in the routine follow-up of patients after pacemaker implantation, attention should be paid to hemoptysis and hemoptysis should be followed closely for bleeding and hemodynamical stability.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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