Two cases of pacemaker-associated haemopericardium with markedly different physiological consequences demonstrate how POCUS can differentiate haemodynamically stable large effusions from true tamponade physiology by evaluating both sonographic findings and clinical presentation.
Key Findings
Background
Pacemaker lead perforation can cause iatrogenic pericardial effusion that may or may not progress to cardiac tamponade.
Pacemaker lead perforation is described as a 'recognised cause of iatrogenic pericardial effusion'
The condition 'may progress to life-threatening cardiac tamponade'
Two distinct clinical presentations were documented in this case pair
One case showed haemodynamic instability with clear tamponade physiology
The other case was initially stable without tamponade despite a massive effusion
Results
A large pericardial effusion following pacemaker lead perforation can be haemodynamically stable without tamponade physiology.
One case presented with a massive pericardial effusion without tamponade
This patient was 'initially stable' despite the large effusion volume
The case illustrates that effusion size alone does not determine haemodynamic consequence
POCUS findings in this case were distinct from classic tamponade sonographic patterns
Results
POCUS demonstrated contrasting sonographic findings between the two cases of pacemaker-associated haemopericardium.
One case showed sonographic features consistent with tamponade physiology alongside haemodynamic instability
The other case showed a massive effusion without sonographic tamponade features
The case pair was used to illustrate how POCUS distinguishes haemodynamically stable effusions from true tamponade
Integration of sonographic findings with clinical presentation was required for accurate differentiation
Discussion
Point-of-care ultrasound is essential for rapid bedside evaluation of pacemaker lead perforation and pericardial effusion.
POCUS is described as 'essential for rapid bedside evaluation'
Differentiation between a large but haemodynamically stable effusion and true tamponade physiology 'requires integration of sonographic findings and clinical presentation'
The authors emphasize 'the importance of evaluating both the heart and the patient as a whole'
POCUS findings alone are insufficient without correlating clinical haemodynamic status
Conclusions
The distinction between haemodynamically stable large effusion and true tamponade requires combined assessment of sonographic and clinical findings.
Sonographic findings must be integrated with clinical presentation for accurate diagnosis
A massive effusion without tamponade physiology represents a clinically distinct entity from tamponade
The cases underscore that ultrasound findings must not be interpreted in isolation
The authors frame this as evaluating 'both the heart and the patient as a whole'
What This Means
This research presents two patients who experienced a complication where pacemaker leads punctured through the heart wall, causing blood to collect in the sac surrounding the heart (haemopericardium). Despite both patients having pacemaker-related bleeding around the heart, their conditions were very different: one patient became dangerously unstable due to cardiac tamponade — a life-threatening condition where fluid compresses the heart and prevents it from pumping properly — while the other patient remained relatively stable even though they had a very large fluid collection. The key tool used to evaluate both patients at the bedside was point-of-care ultrasound (POCUS), a portable imaging technique that can be performed rapidly without moving patients to a radiology suite.
This research suggests that the size of a pericardial effusion alone does not determine how sick a patient is. True cardiac tamponade involves specific ultrasound patterns (such as compression of heart chambers) combined with signs of haemodynamic instability, and these features can be absent even when the effusion is massive. Clinicians using POCUS must look at both what the ultrasound shows and how the patient is actually doing clinically — heart rate, blood pressure, and other signs — to make the correct diagnosis and treatment decision.
The practical implication of this case pair is that emergency and critical care providers should resist the temptation to treat a large effusion as automatically requiring emergency drainage (pericardiocentesis) without confirming true tamponade physiology. Conversely, a smaller effusion with tamponade features and clinical instability demands urgent intervention. This research reinforces a nuanced, integrated approach to bedside ultrasound interpretation in the setting of pacemaker complications.
Chan J, Davis D, Shafer K, Scott M, Cory S. (2026). Contrasting ultrasound findings in pacemaker lead perforation with and without cardiac tamponade.. BMJ case reports. https://doi.org/10.1136/bcr-2025-271517