Summarize the radiology report findings into an impression within 3 sentences.
    INPUT: The sternotomy wires appear intact and appropriately aligned in comparison to the prior radiograph . The patient is status post ICD placement with leads in the right atrium , right ventricle , and coronary sinus . The patient is status post mitral valve replacement . There is increased lucency at the left apex , however no pleural line is visualized . Heart size is stable . The mediastinal and hilar contours are stable . The pulmonary vasculature is normal . Lungs are clear . There is an unchanged small left pleural effusion . There are no acute osseous abnormalities .
    OUTPUT:
    
1 . Appropriately positioned ICD leads . 2 . Absence of lung markings at the left apex , but no pleural line , which could reflect small apical pneumothorax . 3 . Unchanged left pleural effusion . RECOMMENDATIONS Recommend follow - up chest x-ray in 4 hours to evaluate for small left apical pneumothorax .