Less typical form and less typical clinical picture of atrial wall subacute perforation with atrial lead

A 37-yearold woman had undergone implantation of a permanent pacemaker (DDDR) due to a vasovagal response syndrome (VVS). The procedure went without perioperative complications. Neither the pacing control parameters nor the control chest X-ray detected abnormalities. After less than a month, the patient presented to the emergency department with complaints of chest pain intensifying during deep breathing, fatigue and breathlessness. Chest X-ray, electrocardiography (ECG), transthoracic echocardiogram (TTE) and pacemaker interrogation did not reveal any abnormalities. Therefore the patient was discharged from the hospital with the suggestion to undergo a thorough psychiatric medical examination. After a month of her own research, the patient went to the hospital with her own proper diagnosis and was referred to a cardiology department because of persistent symptoms and onset of shoulder and jaw pain. Results of tests carried out in the department showed various abnormalities. In laboratory tests, decreased levels of red blood cells (RBC) of 3.66 x 10 12 /L, hemoglobin (Hb) of 103 g/L, and hematocrit (Hct) of 0.30 and a markedly elevated value of C-reactive protein (CRP) of 16 434 mg/L (at the standard value of 0 to 5000 mg/L) were observed. TTE (fig. 1). Also, transesophageal echocardiography (TEE) showed moderate