Chest Pain After Pacemaker Implantation

A 64-year-old Caucasian woman with past medical history of dyslipidemia and Parkinson's disease was diagnosed with atrial fibrillation and started on treatment with apixaban and metoprolol. She later had a dual chamber pacemaker placement for sick sinus syndrome and her anticoagulation was held for 3 days prior to procedure. She was discharged home in a stable condition without any immediate perioperative complications and the next day she was started back on her anticoagulation. After about 3 weeks, she developed left sided chest pain radiating to her throat, worse with inspiration, shortness of breath, and passed out for a few seconds. She recovered spontaneously but her chest pain and shortness of breath persisted so she presented to the emergency room (ER).

On presentation, her blood pressure was 70/40 mm Hg with pulse of 110 beats per minute, respiratory rate of 24 per minute, and oxygen saturation of 94% on room air. She did not have any pericardial rub or knock but had elevated jugular venous distention with mild pedal edema. Chest X-ray immediately after pacemaker implantation and ER presentation are as shown in Figure 1. An electrocardiogram did not show any clear ST elevation or ST depressions. Troponin was 0.02 (normal 0.000-0.029 ng/ml), WBC count was 14 K/μL (normal 3.7-11 K/μL), US-CRP of 7.9 (normal <1 mg/L), and ESR 15 mm/hr (normal 0-15 mm/hr). A bedside transthoracic echocardiogram showed a moderate sized pericardial effusion with diastolic collapse of right sided chambers and she underwent urgent pericardiocentesis. The pericardial fluid was clear and negative for infections or neoplastic process. Interrogation of pacemaker showed normal lead thresholds and impedance. Follow up electrocardiogram did not show any evolving changes and troponins were stable.

Figure 1: Chest X-Ray

Figure 1

Which of the following is the most likely etiology of her presentation?

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