Abstract
WEBSITE FEATURE
A 79-year-old man in New York Heart Association functional class II was referred for evaluation because of right-sided heart failure, progressive lower-extremity edema, hepatic congestion, and abdominal ascites. His medical history included mitral valve repair to treat severe mitral regurgitation and atrial fibrillation, and implantable cardioverter-defibrillator (ICD) placement to treat sustained ventricular tachycardia.
At the current presentation, 2-dimensional (2D) transthoracic echocardiography (TTE) with color-flow Doppler revealed severe tricuspid regurgitation (Fig. 1A) and substantially diminished right ventricular function. Three-dimensional (3D) TTE from the right atrial side (Fig. 1B) showed entrapment of the posterior leaflet of the tricuspid valve by the ICD lead, with restrained motion of that leaflet clearly visible on motion images. The anterior and septal leaflets displayed normal motion.
Fig. 1 A) Two-dimensional transthoracic echocardiogram (off-axis apical four-chamber view) with color-flow Doppler shows severe tricuspid regurgitation (TR).
B) Three-dimensional transthoracic echocardiography from the right atrial side shows entrapment of the posterior tricuspid leaflet (PL) by the implantable cardioverter-defibrillator lead (*), with normal motion of the anterior (AL) and septal (SL) leaflets.
Real-time motion image of Figure 1B is available at www.texasheart.org/journal.
Comment
Substantial tricuspid regurgitation due to tricuspid leaflet dysfunction caused by ICD leads has been noted in the medical literature,1–4 although its true prevalence is not well established. The mechanisms of device-related tricuspid regurgitation include leaflet perforation or laceration, interference of coaptation by the lead, asynchronous right ventricular activation from apex to base, and entrapment and encapsulation of the device lead by scar tissue.2 There are no guidelines for the management of device lead-related tricuspid leaflet entrapment, although lead extraction has been performed using surgical and noninvasive methods. Freeing the leads from adhesions or scar tissue on the valve leaflet can cause serious complications. Therefore, clear delineation of cardiac structure, and of the device lead and its relationship to the tricuspid leaflets, is necessary to guide treatment, whether surgical or nonsurgical. Iatrogenic tricuspid leaflet entrapment is not often seen clearly on traditional 2D TTE, because of limitations in showing all 3 leaflets of the tricuspid valve in the same view. Conversely, 3D TTE is an excellent tool in the diagnosis of pacemaker-induced leaflet entrapment.1,4
Supplementary Material
Footnotes
Address for reprints: Rajeev L. Narayan, MD, Mount Sinai Heart, One Gustave L. Levy Pl., New York, NY 10029
E-mail: rajeev.narayan@mountsinai.org
References
- 1.Chen TE, Wang CC, Chern MS, Chu JJ. Entrapment of permanent pacemaker lead as the cause of tricuspid regurgitation. Circ J 2007;71(7):1169–71. [DOI] [PubMed]
- 2.Iskandar SB, Ann Jackson S, Fahrig S, Mechleb BK, Garcia ID. Tricuspid valve malfunction and ventricular pacemaker lead: case report and review of the literature. Echocardiography 2006;23(8):692–7. [DOI] [PubMed]
- 3.Lin G, Nishimura RA, Connolly HM, Dearani JA, Sundt TM 3rd, Hayes DL. Severe symptomatic tricuspid valve regurgitation due to permanent pacemaker or implantable cardioverter-defibrillator leads. J Am Coll Cardiol 2005;45(10):1672–5. [DOI] [PubMed]
- 4.Nucifora G, Badano LP, Allocca G, Gianfagna P, Proclemer A, Cinello M, Fioretti PM. Severe tricuspid regurgitation due to entrapment of the anterior leaflet of the valve by a permanent pacemaker lead: role of real time three-dimensional echocardiography. Echocardiography 2007;24(6):649–52. [DOI] [PubMed]
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