Introduction: Late perforation is a very rare complication following pacemaker. Late perforation occurs more than a month after implantation. This is often an unrecognized complication with high morbidity and mortality. (1) We present a patient who is presented with pain in the left side of the thorax one month after implantation of the electrostimulator.

Case report: Male, 82 years. Anticoagulated with warfarin for recurrent deep vein thrombosis. 24-hours Holter ECG: AV block I-II degree Mobitz II 3: 1. Since AV block II stage Mobitz II is rare, because of age and comorbidities of the patient, a single lead pacemaker is implanted as a “back up”. The operation was without complications. One month after the implant, the patient presented with sudden pain in the left hemithorax, hemodynamicaly stable, in ECG sinus rhythm 70 beats per minute, PQ prolongation, the laboratory results: hypersaturation with warfarin (PV 0.14). X ray describes a newly described infiltration in the left thoracic region without high inflammatory parameters. Chest MSCT describes active bleeding from the apex of the right ventricle with a hemorrhagic effusion in the left pleural cavity 5.5cm wide with a smaller pericardial effusion. The patient soon became hemodynamically unstable. After resuscitation and blood transfusions, crystalline solutions and correction of coagulation parameters, the patient was stabilized and a cardiac surgery was performed. Intraoperative, ventricular electrode was located in the pleural space with myocardial and pericardial perforation. During operation, 4 liters blood was evacuated, perforation was stitched and an epicardial electrode was placed. Procedure went without complications and patient was hemodynamically stable.

Conclusion: It is important to bear in mind the late complications of pacemaker implantation and, in case of complications, respond adequately and quickly.