Pulmonary hemorrhage after cardiac resynchronization therapy device implantation – A systematic review


      Cardiac implantable electronic devices are being increasingly used for a variety of cardiovascular diseases. We describe a rare case of massive hemoptysis after device implantation. The patient was managed conservatively with reversal of anticoagulation and inhaled tranexamic acid and had a successful recovery. A systematic review accompanies the case presentation. The modality and difficulty of access appear to play a significant role in precipitating bleeding, believed to be the result of direct injury to the pulmonary parenchyma and vasculature. The condition is often self-limiting; however, anticoagulation reversal, intubation, endobronchial intervention, and transarterial embolization may be indicated in more severe pulmonary hemorrhage.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of the Medical Sciences
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Kurtz SM
        • Ochoa JA
        • Lau E
        • et al.
        Implantation trends and patient profiles for pacemakers and implantable cardioverter defibrillators in the United States: 1993–2006.
        Pacing Clin Electrophysiol. 2010 Jun; 33; : 705-711
        • Cleland JG
        • Daubert JC
        • Erdmann E
        • et al.
        The effect of cardiac resynchronization on morbidity and mortality in heart failure.
        N Engl J Med. 2005 Apr 14; 352: 1539-1549
        • Fox M
        • Mealing S
        • Anderson R
        • et al.
        The clinical effectiveness and cost-effectiveness of cardiac resynchronisation (biventricular pacing) for heart failure: systematic review and economic model.
        Health Technol Assess. 2007 Jan 1; 11 (iii-v)
        • Hummel JD
        • Coppess MA
        • Osborn JS
        • et al.
        Real-world assessment of acute left ventricular lead implant success and complication rates: results from the attain success clinical trial.
        Pacing Clin Electrophysiol. 2016 Nov; 39; : 1246-1253
        • Liberati A
        • Altman DG
        • Tetzlaff J
        • et al.
        The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.
        J Clin Epidemiol. 2009; 62: e1-e34
      1. Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia. [Internet]. Available from: Available at

        • Larsson B
        • Elmqvist H
        • Ryden L
        • et al.
        Lessons from the first patient with an implanted pacemaker: 1958–2001.
        Pacing Clin Electrophysiol. 2003 Jan; 26; : 114-124
        • Bongiorni MG
        • Proclemer A
        • Dobreanu D
        • et al.
        conducted by the Scientific Initiative Committee, European Heart Rhythm Association, Blomström-Lundqvist C, Bongiorni MG, Chen J, Dagres N. Preferred tools and techniques for implantation of cardiac electronic devices in Europe: results of the European Heart Rhythm Association survey.
        Europace. 2013 Nov 1; 15: 1664-1668
        • Aizawa Y
        • Negishi M
        • Kashimura S
        • et al.
        Predictive factors of lead failure in patients implanted with cardiac devices.
        Int J Cardiol. 2015 Nov 15; 199: 277-281
        • Sharma G
        • Senguttuvan NB
        • Thachil A
        • et al.
        A comparison of lead placement through the subclavian vein technique with fluoroscopy-guided axillary vein technique for permanent pacemaker insertion.
        Can J Cardiol. 2012 Sep 1; 28: 542-546
        • Tagliari AP
        • Kochi AN
        • Mastella B
        • et al.
        Axillary vein puncture guided by ultrasound vs cephalic vein dissection in pacemaker and defibrillator implant: a multicenter randomized clinical trial.
        Heart rhythm. 2020 Sep 1; 17: 1554-1560
        • Squara F
        • Tomi J
        • Scarlatti D
        • et al.
        Self-taught axillary vein access without venography for pacemaker implantation: prospective randomized comparison with the cephalic vein access.
        Ep Europace. 2017 Dec 1; 19: 2001-2006
        • Ramza BC
        • Lawrence Rosenthal MD
        • Richard Hui MD
        • et al.
        Safety and effectiveness of placement of pacemaker and defibrillator leads in the axillary vein guided by contrast venography.
        Am J Cardiol. 1997 Oct 1; 80: 892-896 (97)00542-0
        • Tagliari AP
        • Kochi AN
        • Mastella B
        • et al.
        Ultrasound-guided axillary vein puncture in cardiac lead implantation: time to move to a new standard access?.
        Arrhythmia Electrophysiol Rev. 2020 Aug; 9; : 78
      2. Bagchi A, Agarwal RK, Kishan K. Hemoptysis after subclavian vein puncture for pacemaker implantation: a case report. 10.29328/journal.jccm.1001065

        • Bankir M
        • Koc AS
        • Gorgulu FF
        • et al.
        Hemoptysis and massive focal alveolar hemorrhage after successful biventricular pacemaker implantation.
        Nigerian J Clin Practice. 2021 Mar 1; 24: 443
        • Goldberg A
        • Rosenfeld I
        • Marmor A.
        Hemoptysis-a rare complication of pacemaker implantation.
        Indian Pacing Electrophysiol J. 2008 Jan; 8; : 75
        • Kossaify A
        • Nicolas N
        • Edde P.
        Hemoptysis after subclavian vein puncture for pacemaker implantation: importance of wire-guided venous puncture.
        Clin Med Insights. 2012 Jan; 5; (CCRep- S10006.)
        • Tokue H
        • Tokue A
        • Morita H
        • et al.
        Successful interventional management for pulmonary arterial injury secondary to pacemaker implantation.
        Case Rep Cardiol. 2016 Nov 2; (2016)
        • Yelgec NS
        • Osken A
        • Turkkan C
        • et al.
        Subclavian vein puncture-induced massive pulmonary hemorrhage and hemoptysis during pacemaker implantation.
        Northern Clin Istanbul. 2018 Sep 1; 5: 254
        • Antonelli D
        • Atar S
        • Bloch L.
        Hemoptysis after subclavian vein puncture.
        Harefuah. 2007 Oct 1; 146: 744-816
        • Duque FG
        • Gómez JM
        • Pedescoll RS.
        Hemoptysis, a rare complication of punction-catheterization of the subclavian vein.
        Rev Clin Esp. 1994 Mar; 194; : 202
        • Bernardo E
        • Anders M
        • Schmees L
        • et al.
        1202: inhaled tranexamic acid for pulmonary hemorrhage in critically ill pediatric patients.
        Crit Care Med. 2019 Jan 1; 47: 577
      3. O'Neil ER, Schmees LR, Resendiz K, et al. Inhaled tranexamic acid as a novel treatment for pulmonary hemorrhage in critically Ill pediatric patients: an observational study. Critical care explorations. 2020 Jan; 2 (1). 10.1097/CCE.0000000000000075

        • Wand O
        • Guber E
        • Guber A
        • et al.
        Inhaled tranexamic acid for hemoptysis treatment: a randomized controlled trial.
        Chest. 2018 Dec 1; 154: 1379-1384