Pan pneumo: an unusual complication following pacemaker implantation.

Implantation of cardiac devices is usually considered to be a safe procedure. Rare complications, such as pneumothorax, may occur after the procedure. The association with pneumopericardium or pneumomediastinum is even more uncommon. We present the case of a patient in his 70s, on haemodialysis, admitted for complete atrioventricular block. He underwent implantation of a dual-chamber pacemaker. He presented with chest pain the day after implantation. Chest CT scan revealed a pneumothorax associated with a pneumopericardium and pneumomediastinum 'pan pneumo', due to an atrial perforation. We opted for a conservative management strategy. Repeat CT scan of the chest 8 days after the procedure showed a complete resorption of the 'pan pneumo'. The objective of this case report is to describe this rare complication and provide further insight into its management, particularly in the absence of specific guidelines.

Coronary artery spasm and dobutamine stress echocardiography.

AIMS: The aim of this article was to assess whether abnormal dobutamine stress echocardiography (DSE) can be due to a dobutamine-induced coronary spasm in patients with angiographically documented vasospastic coronary arteries. METHODS AND RESULTS: Between January 2004 and April 2008, we prospectively evaluated all patients with known or suspected coronary artery disease (CAD) referred to the echocardiography laboratory for dobutamine stress tests (6061 examinations). Those with abnormal DSE underwent coronary angiogram with a systematic methylergometrine intracoronary injection in the case of absence of significant coronary stenosis or spontaneous occlusive coronary spasm. Patients who had spontaneous occlusive coronary spasm or positive methylergometrine test, but no significant stenoses, were ultimately included in this study. About 581 patients had abnormal DSE, among them only 20 (3.4%) fulfilled the inclusion criteria. There were 15 males and 5 females, and mean age was 64.35 years (range 52-85); 8 patients had a known history of CAD and all of them had at least two established cardiovascular risk factors. The culprit vessel was the left anterior descending artery in 10 cases (50%), right coronary artery in 8 cases (40%), and left circumflex in 2 cases (10%). There was a systematic correspondence between the culprit arteries and dobutamine-induced wall motion abnormality territories. No complications occurred during examination or during the provocation test. All the patients were discharged with a calcium channel blocker and were doing well after 13 months of mean follow-up. CONCLUSION: Coronary artery spasm can be induced at DSE, but is a rare finding; it could, though, be clinically relevant as it may partly explain some erroneously labelled 'false-positive' examinations. Methylergometrine provocation test is a safe and advisable approach in such situations.