Clinical Practice and Cases in Emergency Medicine

Introduction: Delayed cardiac tamponade is a rare but life-threatening complication following permanent pacemaker placement and may present with non-specific symptoms. 

Case Report: We report the case of a 66-year-old woman on oral anticoagulation who presented with generalized weakness, nausea, and profound hypotension four days after dual-chamber pacemaker placement. Initial evaluation demonstrated atrial fibrillation with rapid ventricular response, a normal chest radiographic findings, prerenal azotemia, and no evidence of device malfunction on interrogation. Point-of-care ultrasound (POCUS) performed in the emergency department revealed a large pericardial effusion with right atrial and right ventricular collapse and a plethoric inferior vena cava, consistent with cardiac tamponade. Emergent pericardiocentesis yielded 400 mL of sanguinous pericardial fluid with rapid hemodynamic improvement. Subsequent imaging revealed a 2-mm protrusion of the right atrial lead into the myocardium, which was suspected to be the source of the effusion, but pacemaker revision was not necessary. 

Conclusion: This case highlights the limitations of routine diagnostic testing following permanent pacemaker placement and emphasizes the importance of early POCUS in patients with atypical presentations, particularly in the setting of anticoagulation.