*2.1.4 Pericardial effusion/tamponade*

During device implantation, it is possible that patients may have an acute pericardial bleed leading to either pericardial effusion or pericardial tamponade [17]. Typically, patients have chest pain, tachycardia, and clinical features consistent with cardiogenic shock [30]. Pericardial chest pain typically radiates toward the shoulder blades and also toward the trapezius muscle, at the nape of the neck, due to the pericardial reflection. Further, it may be pleuritic in nature due to rubbing of the pericardium with the pleura [31]. When there is a clinical suspicion for pericardial effusion or pericardial tamponade, immediate imaging is required without any delay; this needs to be addressed immediately, as appropriate treatment is lifesaving. Perforation at the level of the intra-pericardial superior vena cava, right atrium, right atrial appendage, coronary sinus, or right ventricle are all possible and can lead to pericardial effusion [32, 33]. If there is any suspicion of pericardial effusion, immediate fluoroscopic evaluation looking for the lateral movement of the pericardium is useful. Imaging with transthoracic echocardiogram or intracardiac echocardiogram is also of great benefit. Immediate pericardiocentesis will be lifesaving [34]. It is also possible that there may be a slow and progressively worsening pleural effusion, which may not produce any clinical symptoms immediately and patients may present with late pericardial effusion. Minimal or small pericardial effusion could be managed conservatively by following the patient very closely. High dose aspirin, colchicine, and oral corticosteroids can be used to minimize the inflammatory response [31]. However, if there is any hemodynamic compromise, pericardiocentesis is then indicated. Depending on the clinical situation, lead revision may also be indicated (**Figure 2**).

### **2.2 Intermediate chest pain, during the recovery and within 1–2 days**

## *2.2.1 Surgical site pain*

As in any surgical procedure, the most common reason for the pain is usually due to postoperative swelling and will typically respond to simple analgesics and cold compression. In addition to this, it could be due to mechanical reasons including superficial placement of the device within the subcutaneous tissue leading to too much pressure on the skin, lateral device placement in the infraclavicular region leading to mechanical irritation of the axillary nerve, nerve entrapment, etc. [35–37]. Very rarely, patients can also develop allergic reactions to the components of the CIED including titanium, cadmium, chromium, and nickel [38–40]. As these patients are typically advised to use an arm sling, their arm movements can be completely restricted which in turn could lead to shoulder pain [41, 42]; this is similar to early phase of adhesive capsulitis.

**51**

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

As discussed above, pneumothorax, pneumopericardium, hydropneumothorax, and pericardial effusion can produce delayed symptoms of pleural or pericardial pain leading to chest pain. This is typically due to a break in the continuity of the pleural or pericardial membrane secondary to lead perforation. It could be secondary to micro or macro perforations [43–45]. Nevertheless, patient symptoms of chest pain have to be evaluated very carefully and investigated accordingly. Simple chest X-ray and transthoracic echocardiogram would be sufficient in most cases [46]. Use of a CT chest could result in overreading lead perforation due to the presence of artifacts [47]. If there is any clinical suspicion for lead dislodgment, in most

Patients may develop stress cardiomyopathy/Takotsubo cardiomyopathy, in the postoperative period. Clinically, they may present with chest pain, shortness of breath, new onset arrhythmias, and positive troponins. Transthoracic echocardiogram will show apical ballooning and basal septal sparing [48]. Cardiac catheterization can confirm the absence of any major obstructive coronary artery disease. Even though the pathophysiology of the stress cardiomyopathy is evident, etiology of stress cardiomyopathy in the setting of pacemaker implantation is not very clear. This could be secondary to the stress events which led to the device implantation, medications used for sedation, pacing induced dyssynchrony, and/or due to the

In a small percent of the population, it is possible that patients may have diaphragmatic pacing due to direct capture of the phrenic nerve [52]. This can be

cases, lead revision would take care of the chest pain immediately.

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

*2.2.2 Pleuritic/pericardial involvement*

*CT chest showing pericardial effusion.*

**Figure 2.**

*2.2.3 Stress cardiomyopathy*

*2.2.4 Diaphragmatic pacing*

stress of the surgical procedure itself [49–51].

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

#### **Figure 2.** *CT chest showing pericardial effusion.*

*Differential Diagnosis of Chest Pain*

under fluoroscopic guidance.

also be indicated (**Figure 2**).

similar to early phase of adhesive capsulitis.

*2.2.1 Surgical site pain*

*2.1.4 Pericardial effusion/tamponade*

level of the first rib is a preferred approach as it allows for manual compression in this situation [25, 26]. After getting access into the central system, it is very important to advance the guide wire below the diaphragm to confirm placement within the inferior vena cava and not in the arterial side prior to introduction of the sheath. This way, even if there is any inadvertent arterial access, the chances of mediastinal bleeding will be minimized. In the elderly patients, the venous system could be very tortuous especially at the level of the brachiocephalic system [27–29]. Hence, the wire and the sheath have to be advanced very carefully. If there is any resistance noted during advancement of the sheath, further advancement has to be done

During device implantation, it is possible that patients may have an acute pericardial bleed leading to either pericardial effusion or pericardial tamponade [17]. Typically, patients have chest pain, tachycardia, and clinical features consistent with cardiogenic shock [30]. Pericardial chest pain typically radiates toward the shoulder blades and also toward the trapezius muscle, at the nape of the neck, due to the pericardial reflection. Further, it may be pleuritic in nature due to rubbing of the pericardium with the pleura [31]. When there is a clinical suspicion for pericardial effusion or pericardial tamponade, immediate imaging is required without any delay; this needs to be addressed immediately, as appropriate treatment is lifesaving. Perforation at the level of the intra-pericardial superior vena cava, right atrium, right atrial appendage, coronary sinus, or right ventricle are all possible and can lead to pericardial effusion [32, 33]. If there is any suspicion of pericardial effusion, immediate fluoroscopic evaluation looking for the lateral movement of the pericardium is useful. Imaging with transthoracic echocardiogram or intracardiac echocardiogram is also of great benefit. Immediate pericardiocentesis will be lifesaving [34]. It is also possible that there may be a slow and progressively worsening pleural effusion, which may not produce any clinical symptoms immediately and patients may present with late pericardial effusion. Minimal or small pericardial effusion could be managed conservatively by following the patient very closely. High dose aspirin, colchicine, and oral corticosteroids can be used to minimize the inflammatory response [31]. However, if there is any hemodynamic compromise, pericardiocentesis is then indicated. Depending on the clinical situation, lead revision may

**2.2 Intermediate chest pain, during the recovery and within 1–2 days**

As in any surgical procedure, the most common reason for the pain is usually due to postoperative swelling and will typically respond to simple analgesics and cold compression. In addition to this, it could be due to mechanical reasons including superficial placement of the device within the subcutaneous tissue leading to too much pressure on the skin, lateral device placement in the infraclavicular region leading to mechanical irritation of the axillary nerve, nerve entrapment, etc. [35–37]. Very rarely, patients can also develop allergic reactions to the components of the CIED including titanium, cadmium, chromium, and nickel [38–40]. As these patients are typically advised to use an arm sling, their arm movements can be completely restricted which in turn could lead to shoulder pain [41, 42]; this is

**50**
