The landscape of cardiac pacemaker technology has undergone significant evolution over the last two decades, transitioning from simple single-chamber devices to sophisticated multi-chamber rate-responsive systems and cardioverter defibrillators. This progression has introduced a complex array of complications inherent to device implantation and operation, encompassing both mechanical and clinical challenges. These complications notably include lead dislodgment, device migration, venous thrombosis, and hemothorax, which not only affect patient outcomes but also impose substantial economic burdens. This review meticulously analyzes these complications, elucidating their mechanisms, clinical implications, and the economic consequences associated with their management. It also outlines current and emerging strategies aimed at mitigating these complications, emphasizing the need for continual updates in clinical practices and protocols. Through this discourse, the review seeks to equip clinicians with a comprehensive understanding of these complications, thereby enhancing the safety and efficacy of cardiac pacing interventions.

BACKGROUND: Trauma is the leading cause of mortality globally. Penetrating chest trauma is a type of injury that occurs when an object pierces the skin and enters the chest wall. The incidence of penetrating chest trauma is high in the Khyber Pakhtunkhwa Province of Pakistan, with firearm injuries being the most common cause.
OBJECTIVE: The objective of this study is to determine the epidemiology and outcome of non-cardiac penetrating chest injuries presented at a tertiary care center in Peshawar.
METHODS:  This retrospective cohort study was conducted from January 2022 to January 2023 at Medical Teaching Institute, Lady Reading Hospital, Peshawar, KPK, Pakistan. Two hundred and three patients who suffered penetrating chest trauma in the Khyber Province of Pakistan between January 2022 and January 2023 were included in this retrospective cohort study. The epidemiology and outcomes were analyzed using IBM SPSS Statistics for Windows, Version 23 (Released 2015; IBM Corp., Armonk, New York, United States).
RESULTS: The mean age of the patients was 30.25 ± 16.674 years. Males comprised 183 (90.1%) of the study sample whereas females comprised only one-tenth 20 (9.9%). Gunshot injuries were the predominant mode of penetrating thoracic trauma comprising 128 (63.05%) of all injuries. Injuries inflicted by knife constituted approximately one-fifth of the presentations 44 (21.67%). The remaining injuries labeled \'Others\' comprised modes such as road traffic accidents and fall injuries where the predominant mechanism was penetrating injury. The latter comprised 31 (15.27%) of the injuries.
CONCLUSIONS: Penetrating chest trauma is common in the Khyber Pakhtunkhwa Province of Pakistan. Gunshot injury is the most common mode. Males are predominantly affected. Most non-cardiac penetrating chest trauma can be managed conservatively.

Bleeding within the pleural space may result in persistent clot formation called retained hemothorax (RH). RH is prone to organization, which compromises effective drainage, leading to lung restriction and dyspnea. Intrapleural fibrinolytic therapy is used to clear the persistent organizing clot in lieu of surgery, but fibrinolysin selection, delivery strategies, and dosing have yet to be identified. We used a recently established rabbit model of RH to test whether intrapleural delivery of single-chain urokinase (scuPA) can most effectively clear RH. scuPA, or single-chain tissue plasminogen activator (sctPA), was delivered via thoracostomy tube on day 7 as either one or two doses 8 h apart. Pleural clot dissolution was assessed using transthoracic ultrasonography, chest computed tomography, two-dimensional and clot displacement measurements, and gross analysis. Two doses of scuPA (1 mg/kg) were more effective than a bolus dose of 2 mg/kg in resolving RH and facilitating drainage of pleural fluids (PF). Red blood cell counts in the PF of scuPA, or sctPA-treated rabbits were comparable, and no gross intrapleural hemorrhage was observed. Both fibrinolysins were equally effective in clearing clots and promoting pleural drainage. Biomarkers of inflammation and organization were likewise comparable in PF from both groups. The findings suggest that single-agent therapy may be effective in clearing RH; however, the clinical advantage of intrapleural scuPA remains to be established by future clinical trials.

Surgical evacuation has long been the standard treatment for hemothorax. However, some patients are not suitable candidates for surgery. Intrapleural fibrinolytic therapy (IPFT) has recently emerged as an effective alternative for managing retained hemothorax. This case report describes two patients with retained hemothorax who were unfit for surgery and were successfully treated with IPFT at our centre. Both patients were deemed unsuitable for surgery due to comorbidities and their overall functional status. They received three cycles of IPFT, each consisting of 2.5 mg of alteplase. This treatment effectively evacuated the retained hemothorax, achieving complete radiological resolution without immediate or delayed complications up to 3 months post-discharge.

Sarcomatous serous effusions are uncommon and diagnostically challenging. Dedifferentiated and pleomorphic liposarcomas are rare tumors in pleural effusions revealing highly pleomorphic tumor cells mimicking carcinoma, mesothelioma, melanoma, and other sarcomas. Hematothoracic effusions further complicate the cytologic diagnosis. Correct cytologic recognition is important. We report pleomorphic liposarcoma cytologically detected in effusion fluid in a 56-year-old man who presented with a massive unilateral pleural effusion. ThinPrep showed hemorrhagic effusion fluid characterized by lysed red blood cells, foamy macrophages, and siderophages intermixed with highly pleomorphic predominantly naked mononuclear and giant nuclei. The aggregated siderophages and vacuolated macrophages could be mistaken for tumor cells, whereas the bare nuclei may be missed as nonspecific degenerate changes. Cellblock sections showed highly pleomorphic mononuclear and multinucleated giant tumor cells with diagnostic lipoblasts, intermixed with foamy macrophages and siderophages. Cellblock immunocytochemistry showed staining for vimentin and S-100 protein in the tumor cells. Other lineage-specific immunomarkers were negative. CD68 and calretinin revealed frequent background macrophages and scarce mesothelial cells. The tumor cells were negative for MDM2 and CDK4. The entertained cytopathologic diagnosis was pleomorphic liposarcoma. Core needle biopsy was procured from the mass. The histopathologic features and immunoprofile of the tissue specimen matched the cytopathologic and immunocytochemical findings confirming the cytologic diagnosis of pleomorphic liposarcoma. Pleomorphic liposarcoma is an unexpected cytologically challenging finding in effusions, particularly when compounded by pitfalls introduced by hemosiderotic fluid. Attention to certain cytologic clues mitigate pitfalls. Cellblock is a valuable diagnostic tool when integrated with relevant negative and positive immunocytochemical markers.

BACKGROUND: Penetrating thoracic injuries have a significant risk of morbi-mortality. Despite the advancements in damage control methods, a subset of patients with severe pulmonary vascular lesions and bronchial injuries persists. In some of these cases, post-traumatic pneumonectomy is required, and perioperative extracorporeal membrane oxygenation (ECMO) support may be required due to right ventricular failure and respiratory failure.
METHODS: A male was brought to the emergency department (ED) with a penetrating thoracic injury, presenting with massive right hemothorax and active bleeding that required ligation of the right pulmonary hilum to control the bleeding. Subsequently, he developed right ventricular dysfunction and ARDS, necessitating a dynamic hybrid ECMO configuration to support his condition and facilitate recovery.
CONCLUSIONS: Penetrating thoracic injuries with severe pulmonary vascular lesions may need pneumonectomy to control bleeding. ECMO support reduces the associated mortality by decreasing the complications rate. A multidisciplinary team is essential to achieve good outcomes in severe compromised patients.

BACKGROUND: Subclavian arterial injury due to blunt trauma is rare but can have devastating outcomes. Massive hemorrhage or limb ischemia might develop depending on the extent of damage, and open repair might be necessary to salvage the limb. However, life-saving treatments should be prioritized in critically unstable patients.
METHODS: A 21-year-old male patient who was transferred to our trauma center following a motorcycle accident. Abdominal and chest computed tomography (CT) revealed right renal injury and massive hemothorax with several rib fractures in the right chest.
METHODS: Right renal injury with multiple extravasations and right 8th intercostal arterial injury were detected during angiography. Emergent exploration with lateral thoracotomy was performed to manage right hemothorax. Pulsating bleeding from the thoracic roof observed in the operative field suggested a subclavian arterial injury. The unstable vital signs did not recover despite massive transfusion, and his right arm had already stiffened. Therefore, endovascular approach was adopted and the second portion of the right subclavian artery was embolized using microcoils and thrombin.
RESULTS: Postoperative intensive care unit management performed to resuscitate patient from multiorgan failure included continuous renal replacement therapy (CRRT). After confirming the demarcation lines, transhumeral amputation of the right arm was performed on admission day 12. The patient recovered from multiorgan failure for more than 3 weeks after the accident; however, the patient survived.
CONCLUSIONS: Limb salvage, albeit critical for quality of life, is not possible in some cases where life-saving measures require its sacrifice. In these cases, quick decision-making by the surgeon is paramount for patient survival. As illustrated in this case, endovascular approaches should be considered less invasive measures to save the patient\'s life.

OBJECTIVE: Post-operative pain after video-assisted thoracoscopic surgery is often treated using thoracic epidural analgesics or thoracic paravertebral analgesics. This article describes a case where a thoracic disc herniation is treated with a thoracoscopic microdiscectomy with post-operative thoracic epidural analgesics. The patient developed a bupivacaine pleural effusion which mimicked a hemothorax on computed tomography (CT).
METHODS: The presence of bupivacaine in the pleural effusion was confirmed using a high performance liquid chromatography method.
RESULTS: The patient underwent a re-exploration to relieve the pleural effusion. The patient showed a long-term recovery similar to what can be expected from an uncomplicated thoracoscopic microdiscectomy.
CONCLUSIONS: A pleural effusion may occur when thoracic epidural analgesics are used in patents with a corridor between the pleural cavity and epidural space.

BACKGROUND: The objective of this study was to describe the causes of haemothorax in cats, patient presentation and outcome.
METHODS: This was a retrospective study based in a university teaching hospital. The electronic case records of cats presenting with a haemothorax between January 2005 and January 2023 were searched. Cases were categorised into \'trauma\', \'neoplasia\', \'coagulopathy\' or \'other\'. Signalment, physical examination, clinical pathology findings, concurrent injuries and diagnostic imaging findings were recorded. The median hospitalisation time was calculated, and survival to discharge was noted.
RESULTS: Twenty-five cats were eligible for inclusion. Twenty cases of haemothorax were traumatic in origin, two were neoplastic, two were \'other\' and one was coagulopathic. Increased respiratory rate (n = 22) and effort (n = 20) were common, and most patients were anaemic at presentation (n = 16). Common concurrent injuries included pulmonary contusions (n = 15) and pneumothorax (n = 11). The median hospitalisation time for the trauma cats was 5 days (range 1‒15). Overall, 83.3% of the cases survived to discharge.
CONCLUSIONS: The limitations of this study are related to its retrospective nature and the relatively small number of cats in the study population.
CONCLUSIONS: Haemothorax requiring a thoracocentesis in cats is rare, with trauma being the most likely cause. These patients tend to have concurrent injuries and require ongoing hospitalisation. Owners can be advised that the short-term outcome is generally favourable.

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