Post Cardiac Injury Syndrome

Hello, I’m a 62 yr old female, had pacemaker surgery on Sept 12, 2019. During the procedure I woke up with excruciating pain in the right side of my chest chest. They were having trouble controlling the bleeding from the surgery site and also had to redo the leads. After surgery, I continued to complain about the pain in my right side when I took a breath or moved, the surgery site was not causing much discomfort. This right side chest pain has continued and on Sept 24 I saw my Primary, who thought I may have cracked a rib. She did some bloodwork and xrays. The xrays show fluid in my right lung, and elevated d dimmer (1195). After hospital admission and rule out of PE, they discharged me without any answers, but I was still in pain. My daughter, who is a nurse, has been looking for answers and came across Post Cardiac Injury Syndrome. Has anyone heard of such a thing after pacemaker surgery? The treatment is anti inflammatories, which I had been taking for teeth pain, but since had stopped. I took some ibuprofen this morning and symptoms have subsided, although not gone. Any other possible answers? Any help would be appreciated. I have a call into my primary with my daughter’s guess. Also, when I told my EP after surgery, he said, “ I have no idea by it would hurt there, it should feel better in a few days”! I am now on day 15 post surgery! Thank you


There's a lot missing here.

by crustyg - 2019-09-27 13:33:08

D-dimer raised - you've probably had a bleed/clot - not necessarily in a vein.  Fluid in or *around* right lung?  Excruciating right sided chest pain.  You say that they had trouble controlling bleeding from the surgery site - right or left?  Doesn't sound cardiac to me.

Here's a wild guess!  It sounds as though they pranged a major vein during lead insertion and these are not easy veins to control bleeding from for the usual placement of pacing leads.

I suspect that if you have a frank conversation with whoever did the PM implantation, armed with a copy of the operation notes (here in the UK we have a legal right to our Health records, including the imaging), they will explain what went wrong.

Or I could be completely wrong!  Remote armchair diagnosis is often wildly out.


by Ddefalco326 - 2019-09-27 23:04:46

Crustyg, yes, d-dimer can be directly related to the bleed during surgery, or just the surgery itself. The pleural effusion, I was told was fluid in my right lung. My PM was placed on the left. I didn’t think it was a cardiac event, but rather happened as a result of cardiac surgery. Reading the description of PCIS, describes most if not all of my symptoms. Thank you for responding !


by Gemita - 2019-09-28 08:03:00

My hubby was officially diagnosed with PCIS following a bleed during pacemaker implantation (because nurses failed to stop his triple therapy well before his procedure unfortunately: Clopidogrel, Aspirin, Apixaban). He got lower left pleural effusion (bloody fluid in the lung that was also infected).  It was drained off the lower left lung and he was given antibiotics and is now relatively well with less chest pain/breathlessness. But it tooks months to treat his symptoms. The pleural effusion has caused pleural thickening which is a concern.  This injury can take a long time to reveal itself or to settle and we were told the pleural effusion could return.  The diagnosis I feel, was one of exclusion when all other investigations proved negative. I wasn't totally convinced I have to say, since hubby does have COPD, ischaemic heart disease, has had several strokes, has AF, stents and now a pacemaker so a lot could have gone wrong.  Yes I agree with your opinion, it has probably happened as a result of your cardiac surgery rather than because of a cardiac event.  Have you had a formal diagnosis ?  I would respectfully suggest if your symptoms continue to follow this up with your doctors again.  Hubby was told not to take anti inflammatories because of the bleeding risk while being on anticoagulant/antiplatelet therapy.  He is now only on low dose Edoxaban because of poor kidney function, for AF stroke protection.  Good luck


by Ddefalco326 - 2019-09-28 09:55:26


Thank you so much for responding. I hope hubby is doing better, as it sounds as he has a lot going on medically. It also sounds as if you also have your hands full with taking care of him. I am fortunate to have my daughter being so vigilant about the quality of care that I receive. I have always been able to advocate for myself and family, but she brings her medical knowledge and expertise to the table, that helps considerably. As my primary has been searching for an explanation, I messaged her with my daughter’s prognosis. I will be following up with her next week. It is so frustrating when drs dismiss you when you complain of pain. This pain was so severe, that it woke me from the sedation during the pm procedure, and has been consistent since. When I questioned if the fluid in my lungs could be blood, the hospital dr acted as if it wasn’t even a possibility. I again hope that your hubby is feeling better. Thank you again for your insight . 

But it's not cardiac...

by crustyg - 2019-09-28 10:59:17


PCIS reflects a collection of symptoms after cardiac injury, most of which start with inflammation of the tough sac that surrounds the heart, the pericardium.  It doesn't *sound* as though that's happened here, IMHO.  Pacemaker + lead implantation isn't cardiac surgery.

My naughty suggestion was that they caused a significant bleed from the axillary vein where the leads are inserted into your blood vessels to gain access to the inside of the heart, and that gave you a haemothorax - fluid *around* the lung, not in it - which causes pleuritic chest pain.  Had anyone tried to tap that fluid, then instead of being a straw-coloured clear fluid it might have been bloody, or frank blood.  I can only hope that you weren't anti-coagulated for the procedure - it shouldn't happen but Gemita says that it happened to her husband.

It can be really easy to push through or tear the axillary vein during lead insertion, and it's not the sort of blood vessel where you can just press on it for a couple of minutes to prevent bleeding, and puncture of the pleura is also possible if the vein has been holed behind (i.e. punctured on the top and bottom), so blood can easily enter the potential space between the two layers of pleura.

Pleuritic chest pain is classically described as sharp, worse on breathing, especially inspiration, often felt at the shoulder tip, difficult to control with opioids and usually responds well to a good anti-inflammatory (NSAID).  I've managed a few patients with it, and suffered a couple of bouts of it myself. It really does feel as though there are two sheets of sandpaper rubbing together inside the chest during inspiration.  And having blood in the pleural space can give rise to pleuritic chest pain.

For me, the 'woke up during the procedure with excruciating pain in.. my chest' is the important part of the history.  Pain can overcome a lot of sedative and pain-suppressing drugs and the sudden onset strongly suggests a causal connection between what they were doing and what you were feeling.  Nobody has trouble controlling the bleeding from the skin incision or pocket during PM implantation (assuming that their coagulating diathermy is working) - the troublesome bleeding tends to arise from where they have made hole(s) in the big vein that will convey the PM lead(s) to the heart.  Unless you're an undiagnosed von Willebrand's sufferer, as Haemophilia A in females is exceptionally rare, while von W is common - and used to be missed quite often in women.  Haemophilia A being missed in men isn't exactly unknown either, but not relevant to you.


by Gemita - 2019-09-29 07:58:23

Ddefalco326 Thank you for your kind comments.  It can be difficult managing my husband's health conditions since he absolutely hates taking all his medication !!  He is convinced it is doing him more harm than good and I have to work hard with his doctors to find the "right balance" for him.  Actually we both have AF and pacemakers now.  Crustyg thank you so much for all the information given.  You obviously have a medical background and we are very lucky to receive this valuable feedback.

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The experience of having a couple of lengths of wire fed into your heart muscle and an electronic 'box' tucked under the skin is not an insignificant event, but you will survive.