Post-Cardiac Injury Syndrome Following Permanent Pacemaker Implantation Presenting Exclusively As Massive Pleural Effusion: A Rare Occurrence.

Post-Cardiac Injury Syndrome (PCIS) akin to Dressler's syndrome is late-onset pericarditis that is triggered by the body's immune system and presents commonly as pleuro- pericardial symptoms and raised inflammatory markers. Its occurrence following the insertion of a pacemaker has been reported infrequently and varies in different studies with an estimated prevalence of 1-2%. Our case reports a unique incidence of isolated pleural effusion following the implantation of a pacemaker in a 62-year-old female with complete heart block with no evidence of pericardial effusion on imaging. She developed dyspnoea, pleuritic chest pain, and lethargy. She successfully responded to treatment with NSAIDs and colchicine with no recurrence. This report demonstrates the uncommon course of the disease and highlights the need to consider PCIS as a possible diagnosis in patients presenting with predominant pulmonary findings and suspect it early so that timely treatment can be started, thereby preventing complications.

Accessory Cardiac Conduction Pathway with an Unusual Presentation.

Pre-excitation syndrome (PES) is a congenital abnormality in which there is conduction through accessory pathway in addition to atrioventricular (AV) node between the atria and the ventricles. Conduction through accessory pathway is without any delay and; hence, results in early excitation of ventricles. This dual connection provides substrate for atrioventricular reciprocating tachycardia (AVRT), a type of supra-ventricular tachycardia. Wolf-Parkinson-White (WPW) syndrome is the commonest form of PES. PES with third degree AV block or complete heart block (CHB) is a rare association. We report here a case of 37-year male with surface ECG findings consistent with PES who presented with syncope. The combination of pre-excitation on ECG with syncope usually draws attention towards tachy-arrhythmias. However, ECG monitoring revealed CHB with intermittent conduction through accessory pathway. It highlights the critical evaluation of PES patients with syncope because therapeutic strategy is entirely different. This case was managed with dual chamber pacemaker implantation instead of accessory pathway ablation.

Persistent left superior vena cava: A disconcerting finding for interventionist.

Persistent left superior vena cava (PLSVC) is one of the commonest venous anomalies of thoracic venous system. These cases usually have normal right sided superior vena cava (SVC). Patients with PLSVC are often asymptomatic hence, it is diagnosed as an incidental finding during procedures like central venous line placement or pacemaker implantation. We report here a case that was taken to catheterization laboratory for pacemaker implantation. Due to PLSVC, we struggled to advance pacing lead into right ventricular apex. We thought of right subclavian vein access but contrast medium injection revealed absent right sided SVC. So procedure was abandoned and finally epicardial placement of the pacing lead was done through subxiphoid laparotomy incision next morning. This case report highlights a rare variant of PLSVC with absent right sided SVC in structurally normal heart and emphasizes the need of pre-procedure assessment of venous anatomy.