**2. Chest pain after CIED implantation**

For practical purposes, the etiology of chest pain after device implantation surgery could be divided based on the time of occurrence. We classified it into the following three categories:


Just like any other surgical process, placing the leads and the devices resulted in various forms of trauma and by itself can produce chest pain. These adverse effects can occur during the procedure, in the immediate postoperative period, and well after the implant procedure.

#### **2.1 Immediate chest pain during the procedure**

#### *2.1.1 Musculoskeletal*

Most of these CIED surgeries are performed with moderate sedation [13]. Patients who undergo CIED surgeries are commonly elderly and have multiple co-morbid conditions [14]. This clearly limits the options for adequate analgesia and sedation due to concerns for adverse effects of sedatives and analgesics. Hence, adequate local anesthesia plays a major role in terms of pain control. If the patients are not adequately anesthetized with local anesthesia, they may experience sharp pain during various parts of device implantation. Even if they are adequately anesthetized with local anesthesia, this will be effective predominantly within the subcutaneous tissue [15]. Furthermore, patients may feel sharp pain when the muscle tissue is being manipulated, especially if they have to have a suture or cauterization of the muscles secondary to inadvertent bleeding. Safe vascular access is very important to minimize the complications of CIED surgery. Hence, most of the operating physicians try to use the junction between the clavicle and first rib as a landmark to minimize the risk of pneumothorax. Typically, the axillary vein can be accessed just at the level of the first rib [16]. If the needle passes the veins "through and through" and hits the periosteum of the first rib, patients may feel this discomfort. After venous access, when the sheath is being advanced into the venous system, it could stretch the periosteum of the costoclavicular ligament which in turn can be uncomfortable for the patient. Hence, during this part of the procedure, it is very important to provide appropriate analgesia for the patient.

#### *2.1.2 Pneumothorax*

Pneumothorax, hemothorax, and hydropneumothorax are some of the dangerous complications after CIED implantation [17]. Implanting-physicians always strive to minimize these complications as they increase the morbidity and mortality. These complications are reduced by using micropuncture access needles, using contrast venography to identify the veins, and using ultrasound to identify the veins [18–20]. In addition to this, some physicians also use a bolus of intravenous fluid to engorge veins. Similarly, Trendelenburg positioning or elevating the patient's legs with a wedge under the leg (without tilting the operating table) could be useful [21]. Some physicians also inject contrast when they are gaining access because the contrast tends to engorge the veins. In spite of these careful and meticulous approaches, sometimes pneumothorax is inevitable. Even though, the vein is accessed via the extrathoracic veins, it is possible that the patients may have a small bleb secondary to COPD, which through inadvertent entry may produce a pneumothorax [22]. Pneumothorax could be suspected at the earliest, when there is

**49**

**Figure 1.**

*Chest X-ray showing right sided pneumothorax.*

*Practical Approach to Chest Pain Related to Cardiac Implantable Electronic Device Implantation*

aspiration of air with the introducer needle, before entering into the venous system. It is also imperative to note that the needle should be attached to the syringe air tight. Otherwise, it could give a false opinion of aspiration of air into the syringe. During access, after entering into the vein, if the patient has obstructive sleep apnea, they could create huge negative intrathoracic pressure during deep inspira-

1.Advancing the needle deep into the lung parenchyma, beyond the first rib

If the operating physician noted any signs of aspiration of air into the syringe, then the patient should be carefully monitored for possible pneumothorax. In addition to this, patients may also develop sudden onset of chest pain, cough, hypoxia or tachycardia. During this situation, fluoroscopy can be implemented immediately to evaluate for any pneumothorax; keeping in mind that supine positioning is not the

Any mediastinal bleed during CIED implantation could produce acute chest pain. This pain is typically very diffuse and radiates toward the posterior aspect of the chest secondary to mediastinal reflection [23, 24]. Patients may manifest tachycardia secondary to sympathetic stimulation and hypotension, depending upon the extent of the blood loss. This is one of the dangerous conditions, which needs to be identified and addressed as soon as possible. Inadvertent access of the subclavian artery could produce mediastinal bleed. Hence, accessing the axillary vein at the

3.Medial puncture (intrathoracic part of the subclavian vein)

*DOI: http://dx.doi.org/10.5772/intechopen.92743*

tion which in turn can suck in air (**Figure 1**).

2.Accidental puncture of superficial blebs

ideal method of assessing for pneumothorax.

*2.1.3 Mediastinal bleed*

Causes of pneumothorax:

#### *Practical Approach to Chest Pain Related to Cardiac Implantable Electronic Device Implantation DOI: http://dx.doi.org/10.5772/intechopen.92743*

aspiration of air with the introducer needle, before entering into the venous system. It is also imperative to note that the needle should be attached to the syringe air tight. Otherwise, it could give a false opinion of aspiration of air into the syringe. During access, after entering into the vein, if the patient has obstructive sleep apnea, they could create huge negative intrathoracic pressure during deep inspiration which in turn can suck in air (**Figure 1**).

Causes of pneumothorax:

*Differential Diagnosis of Chest Pain*

1–2 days)

3.Delayed chest pain

after the implant procedure.

*2.1.1 Musculoskeletal*

*2.1.2 Pneumothorax*

1.Immediate chest pain (during the procedure)

**2.1 Immediate chest pain during the procedure**

2.Post procedural chest pain (in the immediate postoperative period, within

Just like any other surgical process, placing the leads and the devices resulted in various forms of trauma and by itself can produce chest pain. These adverse effects can occur during the procedure, in the immediate postoperative period, and well

Most of these CIED surgeries are performed with moderate sedation [13]. Patients who undergo CIED surgeries are commonly elderly and have multiple co-morbid conditions [14]. This clearly limits the options for adequate analgesia and sedation due to concerns for adverse effects of sedatives and analgesics. Hence, adequate local anesthesia plays a major role in terms of pain control. If the patients are not adequately anesthetized with local anesthesia, they may experience sharp pain during various parts of device implantation. Even if they are adequately anesthetized with local anesthesia, this will be effective predominantly within the subcutaneous tissue [15]. Furthermore, patients may feel sharp pain when the muscle tissue is being manipulated, especially if they have to have a suture or cauterization of the muscles secondary to inadvertent bleeding. Safe vascular access is very important to minimize the complications of CIED surgery. Hence, most of the operating physicians try to use the junction between the clavicle and first rib as a landmark to minimize the risk of pneumothorax. Typically, the axillary vein can be accessed just at the level of the first rib [16]. If the needle passes the veins "through and through" and hits the periosteum of the first rib, patients may feel this discomfort. After venous access, when the sheath is being advanced into the venous system, it could stretch the periosteum of the costoclavicular ligament which in turn can be uncomfortable for the patient. Hence, during this part of the procedure,

it is very important to provide appropriate analgesia for the patient.

Pneumothorax, hemothorax, and hydropneumothorax are some of the dangerous complications after CIED implantation [17]. Implanting-physicians always strive to minimize these complications as they increase the morbidity and mortality. These complications are reduced by using micropuncture access needles, using contrast venography to identify the veins, and using ultrasound to identify the veins [18–20]. In addition to this, some physicians also use a bolus of intravenous fluid to engorge veins. Similarly, Trendelenburg positioning or elevating the patient's legs with a wedge under the leg (without tilting the operating table) could be useful [21]. Some physicians also inject contrast when they are gaining access because the contrast tends to engorge the veins. In spite of these careful and meticulous approaches, sometimes pneumothorax is inevitable. Even though, the vein is accessed via the extrathoracic veins, it is possible that the patients may have a small bleb secondary to COPD, which through inadvertent entry may produce a pneumothorax [22]. Pneumothorax could be suspected at the earliest, when there is

**48**


If the operating physician noted any signs of aspiration of air into the syringe, then the patient should be carefully monitored for possible pneumothorax. In addition to this, patients may also develop sudden onset of chest pain, cough, hypoxia or tachycardia. During this situation, fluoroscopy can be implemented immediately to evaluate for any pneumothorax; keeping in mind that supine positioning is not the ideal method of assessing for pneumothorax.
