Background: Tube thoracostomy is a routine life-saving procedure with vast implications in the management of various thoracic conditions that include pleural effusion, pneumothorax, empyema, blunt, and penetrating thoracic trauma. Though a simple procedure, a high rate of morbidity and mortality is associated if a complication occurs. Case Presentation: An intercostal chest tube was inserted by trocar method in a 47-year-old female with rheumatic heart disease associated cardiomegaly, which resulted in right atrial perforation. The patient was managed successfully by an emergency thoracotomy followed by cardiac repair surgery. Our case report demonstrates a very unusual yet life-threatening complication of a simple intervention such as intercostal chest tube insertion and highlights the management of the same. Aim of this case report is to discuss the clinical implications and literature pertaining to the iatrogenic cardiac injury during tube thoracostomy. Conclusion: The use of the blind method of intercostal chest drain insertion using a trocar should be discouraged, particularly in cases with dense pleural adhesions or cardiomegaly.

Keywords: Cardiac perforation, cardiothoracic surgery, healthcare improvement, patient safety, tube thoracostomy