(searched for: A Rare Fatal Case of Cardiac Perforation During Cardioverter-Defibrillator Implantation)
Journal of Rural Medicine, Volume 15, pp 63-64; doi:10.2185/jrm.2019-007
Although methemoglobinemia is rare in adulthood, it may have fatal consequences if unnoticed. We planned to implant an implantable cardioverter defibrillator ICD in a 50-year-old male patient for primary prevention. Following sterile draping, prilocaine 5 mg/kg (400 mg) was injected subcutaneously for local anesthesia. We injected an additional dose of 200 mg due to pain during subclavian vein puncture. A DDD-R ICD was placed successfully within approximately 40 minutes. The patient complained of sudden chest pain and dyspnea 15 minutes after bed rest and was transferred to the coronary care unit due to cyanosis and deterioration of general status. Physical examination revealed blood pressure of 110/80 mmHg, pulse rate of 110 bpm, and otherwise unremarkable signs. Peripheral oxygen saturation was determined as 83% by pulse oximeter. Possible pneumothorax and cardiac perforation were excluded by emergency chest radiograph and echocardiography. Blood gas analyses was performed to assess for methemoglobinemia, which revealed pH 7.41, pCO2 40 mmHg, oxygen saturation 98.2%, and methemoglobin 7.9% that peaked to 12.3%. Methylene blue (1%) was slowly injected over 10 minutes at a dose of 1 mg/kg. Cyanosis waned and methemoglobin values decreased to 4.1%, 2.1%, and 1.1% at 2, 8, and 16 hours following the administration, respectively. The patient was safely discharged 2 days after implantation of pacemaker. Methemoglobinemia should be considered in cases presenting with cyanosis, non-diagnostic ECG, and a discrepancy in oxygen saturation between pulse oximetry and blood gas analyses.
Archives of Clinical and Medical Case Reports, Volume 4, pp 638-644; doi:10.26502/acmcr.96550241
Right ventricular perforation is a rare but fatal complication during implantation and removal of cardiac devices. The causes of such an event are not well defined, although among the various factors involved, the thickness of the ventricular wall and the force exerted by the operator appear to be important. We report here a case of fatal cardiac resynchronization therapy with defibrillation in a patient without apparent predictive factors for perforation. This case highlights the importance of revisiting the diagnostic pathways before introduction of a cardiac device, and of further studies on the predictive factors, to avoid a complication being considered as a surgical error.