Tricuspid valve stenosis related to subvalvular adhesion of pacemaker lead: a case report

Endocardial pacemaker leads may cause tricuspid valve regurgitation, but only four cases of tricuspid stenosis without endocarditis have been reported. A 77-year-old woman had received three endocardial leads when aged 44, 57, and 72 years. One lead pushed up the septal leaflet of the tricuspid valve from below the valve, then adhered to the leaflet, and was positioned against the ventricular septum. Tricuspid valve stenosis and moderate regurgitation were separately detected by transthoracic echocardiography. The tricuspid valve orifice area was 0.93 cm2 at cardiac catheterization. An excessive loop of a ventricular lead, especially a subvalvular loop, can cause opening limitation of the tricuspid valve, and the entangling of the lead in the subvalvular structures can easily induce reactive fibrosis and adhesions.     

A New View of an Unusual Pacemaker Complication: Role of Three‐Dimensional Transthoracic Echocardiography

Tricuspid regurgitation (TR) produced by endocavitary leads (EL) from permanent pacemakers and implantable cardiac defibrillators is a well‐known complication of this procedure. The EL may damage or interfere with tricuspid valve function causing mechanical interference of the valve leaflets leading to incomplete valve closure. It is important to recognize this mechanical complication because it could be corrected by repositioning the lead. In this case report we demonstrate how three‐dimensional transthoracic echocardiography permits to obtaining an en face view, which allows simultaneous visualization of the 3 moving leaflets during the cardiac cycle, their attachment to the tricuspid annulus and the pattern of leaflet coaptation. Thus, we propose three‐dimensional transthoracic echocardiography as the tool of choice to evaluate TR related to EL, to evaluate the necessity of repositioning the lead if severe regurgitation or tricuspid valve malfunction are demonstrated.     

Severe symptomatic tricuspid valve regurgitation due to permanent pacemaker or implantable cardioverter-defibrillator leads

OBJECTIVES: We report a series of patients with severe tricuspid valve regurgitation due to a permanent pacemaker (PPM) or implantable cardioverter-defibrillator (ICD) lead. BACKGROUND: Severe tricuspid regurgitation caused by a PPM or ICD lead is an under-recognized but treatable etiology of severe right heart failure. METHODS: We reviewed the records of 41 patients who underwent tricuspid valve operation for severe tricuspid regurgitation caused by previously placed PPM or ICD leads. RESULTS: During surgery, severe tricuspid regurgitation was found to be caused by the PPM or ICD leads in all 41 patients. There was a perforation of the tricuspid valve leaflet by the PPM or ICD lead in 7 patients, lead entanglement in the tricuspid valve occurred in 4 patients, lead impingement of the tricuspid valve leaflets occurred in 16 patients, and lead adherence to the tricuspid valve occurred in 14 patients. The septal leaflet was most often perforated (6 of 7). In the preoperative evaluation, valve malfunction due to the PPM or ICD lead was diagnosed preoperatively in only 5 of 41 (12%) patients by transthoracic echocardiography. All patients underwent successful tricuspid valve operation (22 tricuspid valve replacement), with one perioperative death occurring. During follow-up (range, 1 to 99 months), there was one patient who died from left-sided heart failure and three patients died of other causes. The remaining patients showed improvement in signs and symptoms of heart failure. CONCLUSIONS: Damage to the tricuspid valve by PPM or ICD leads may result in severe symptomatic tricuspid regurgitation and may not be overtly visualized by echocardiography. This etiology should be considered when evaluating patients with severe right heart failure after PPM or ICD implantation.     

右房左右径大小对右室起搏导线植入难度和稳定性的影响

目的根据近3年新发12例心室导线脱位病例的临床特点和心脏超声改变,分析尚未充分认识到的原因。方法分析12例施行心室导线脱位后复位术病例,并与同期160例未脱位病例的右房左右径、上下径以及右室上下径、三尖瓣返流程度、手术耗时、心室导线定位前的跨瓣次数。结果脱位病例的心脏参数和跨瓣次数均大于或多于未脱位者。心室导线跨越三尖瓣环困难是其共同点。螺旋电极尽管不能解决跨瓣困难的问题,但可以在心室导线一旦进入心室后,迅速定位、固定良好。复位成功率100%。结论右房结构异常,主要是右房左右径对心室导线植入难度以及稳定性存在明显影响,选用主动固定螺旋电极可能会减少脱位的发生。     

Right ventricular and tricuspid valve function in patients with two ventricular pacemaker leads

Existing data on the effect of retained pacemaker leads on right ventricular (RV) and tricuspid valve function is limited. OBJECTIVE: In this echocardiographic study we investigated the long-term effect of retained ventricular leads on RV and tricuspid valve function in patients with permanent pacemakers. Forty patients, 18 with two (group I) and 22 with one (group II) ventricular lead were assessed echocardiographically at an average of 39 months after the second lead implantation in group I and 80 months after the lead implantation in group II. The sum of the lead body diameter in group I was significantly greater than the body diameter in group II (P < 0.000). There was no significant difference between the groups with respect to chamber diameters and ventricular or valvular functions. The distributions of the different tricuspid regurgitation (TR) grades were similar, with the majority of patients in both groups having mild TR. Retained second pacemaker leads do not have an additional negative effect on right ventricular and tricuspid valve function.     

Tricuspid valve repair for torrential tricuspid regurgitation after permanent pacemaker lead extraction

Tricuspid regurgitation secondary to percutaneous lead extraction is uncommon, and it rarely requires surgical intervention. Most tricuspid regurgitation occurs during the implantation of tined leads, which can be entrapped in the tricuspid valve apparatus and may require immediate withdrawal. Severe tricuspid regurgitation as a sequela of extracting chronically implanted leads has rarely been reported. Herein, we report a case of torrential tricuspid regurgitation in a 67-year-old woman after the extraction of a permanent pacemaker lead. The regurgitation was confirmed on transesophageal echocardiography during lead extraction, and the tricuspid valve was successfully repaired with suture bicuspidization of the valve and the support of ring annuloplasty. A short review of the relevant literature follows the case report.     

Isolated rheumatic severe tricuspid regurgitation

Severe isolated tricuspid regurgitation (TR) is very rare, with most cases of TR being functional and secondary to pulmonary hypertension from left heart pathologies. We report an unusual case of a young Nigerian male, who presented to us with dyspnea, repeated hospital admissions for heart failure, and a childhood history of rheumatic fever. Echocardiogram showed massively dilated right atrium and ventricle, noncoaptation of thickened tricuspid valve with torrential free tricuspid regurgitation. Other valves were normal. Cardiac MRI showed normal right ventricular function and viability. Patient underwent tricuspid valve replacement with 35‐mm St. Jude valve.     

Predictors of Severe Tricuspid Regurgitation in Patients with Permanent Pacemaker or Automatic Implantable Cardioverter-Defibrillator Leads

Patients with permanent pacemaker or automatic implantable cardioverter-defibrillator (AICD) leads have an increased prevalence of tricuspid regurgitation. However, the roles of cardiac rhythm and lead-placement duration in the development of severe tricuspid regurgitation are unclear.We reviewed echocardiographic data on 26 consecutive patients who had severe tricuspid regurgitation after permanent pacemaker or AICD placement; before treatment, they had no organic tricuspid valve disease, pulmonary hypertension, left ventricular dysfunction, or severe tricuspid regurgitation. We compared the results to those of 26 control subjects who had these same devices but no more than mild tricuspid regurgitation.The patients and control subjects were similar in age (mean, 81 ±6 vs 81 ±8 yr; P = 0.83), sex (male, 42% vs 46%; P = 0.78), and left ventricular ejection fraction (0.60 ±0.06 vs 0.58 ± 0.05; P = 0.4). The patients had a higher prevalence of atrial fibrillation (92% vs 65%; P=0.01) and longer median duration of pacemaker or AICD lead placement (49.5 vs 5 mo; P < 0.001). After adjusting for age, sex, and right ventricular systolic pressure by multivariate logistic regression analysis, we found that atrial fibrillation (odds ratio=6.4; P = 0.03) and duration of lead placement (odds ratio=1.5/yr; P = 0.001) were independently associated with severe tricuspid regurgitation.Out study shows that atrial fibrillation and longer durations of lead placement might increase the risk of severe tricuspid regurgitation in patients with permanent pacemakers or AICDs.Key words: Atrial fibrillation/complications, cardiac pacing, artificial/adverse effects, defibrillators, implantable/adverse effects, disease progression, echocardiography, electrodes, implanted/adverse effects, pacemaker, artificial/adverse effects, risk factors, tricuspid valve insufficiency/diagnosis/etiology, ventricular dysfunction, right/diagnosis/etiologyPatients with permanent pacemaker (PPM) or automatic implantable cardioverter-defibrillator (AICD) leads have an increased prevalence of significant tricuspid regurgitation (TR). Tricuspid regurgitation can be caused by various mechanisms, including pulmonary hypertension, direct lead interference with valve closure, tricuspid valve leaflet trauma from laceration and perforation, infective endocarditis, and fibrous adherence of pacemaker leads to the tricuspid valve apparatus.¹ Patients with long-standing atrial fibrillation (AF) can also develop severe TR even when their tricuspid valves are structurally normal.² In addition, patients with PPM leads have an increased prevalence of TR.³ Investigators in several large studies concluded that having a PPM or AICD increases the degree of TR in some patients.^1,3–5 However, it is unclear whether the chronic presence of device leads results in increased TR. We therefore sought to determine the predictors of severe TR in patients who have PPM or AICD leads. We hypothesized that a longer duration of PPM or AICD lead placement and the presence of AF were the chief risk factors.     

Tricuspid valve insufficiency in patients with rheumatic mitral valve disease: angiographic diameter of the tricuspid ring and function of the right ventricle

Dilatation of the right ventricle and a consecutive enlargement of the tricuspid valve ring are thought to be the main causes of functional tricuspid regurgitation in patients with rheumatic mitral valve disease. To study the effect of right ventricular dilatation as well as the dimension of the tricuspid valve ring, right ventricular volume indices, ejection fraction, regional shortening, pulmonary artery pressure, and the diameter and systolic shortening of the tricuspid valve were determined in 67 patients with rheumatic mitral valve disease (NYHA class II and III) from biplane ventriculographies. Patients with right ventricular enlargement (greater than 90 ml/m2) were divided into groups with (group IIA) and without (group IIB) tricuspid regurgitation and compared with patients with normal right ventricular size and function without tricuspid regurgitation (group I). There was no difference in the end-diastolic volume index, in the afterload or in the diameter of the tricuspid ring. Right ventricular ejection fraction was decreased in group IIA (51 +/- 9% vs. 59 +/- 10% (IIB) and 61 +/- 6% (control); (p less than 0.05). Regional function was also decreased in group IIA. 73% of the patients with tricuspid regurgitation had right ventricular enlargement, but only 44% of the patients with right ventricular enlargement had tricuspid regurgitation. Thus right ventricular dilatation promotes the development of a tricuspid insufficiency, but is not the only cause. Additional factors like decreased local wall motion, alterations of the valve or the valve apparatus may also account for functional tricuspid regurgitation.     

Pacing lead entanglement in the tricuspid valve appartus during implantation

During implantation of a permanent pacing lead, the operatorrequested assistance after the lead had been rotated in an attemptto position it at the right ventricular apex. The tines on thelead tip caught on the chordae of the tricuspid valve and thesebecame wrapped around the lead tip. An attempt to remove thelead by rotating in the opposite direction further entangledthe lead. Lead traction resulted in inversion of the right ventricleand it was felt that there was a significant risk of avulsionof the valve or the right ventricle. The lead was eventuallyextracted with counter-traction applied with a subclavian leadextraction sheath and a locking stilette. The image shows thetricuspid chordae wrapped around the lead tip with a small amountof papillary muscle attached. No tricuspid regurgitation wasseen on echocardiography after the procedure. Pacing leads shouldnot be rotated during implantation and traction of trapped leadsmay result in damage to valvular apparatus which may be minimisedby use of counter-traction.     

膜周部室间隔缺损合并三尖瓣中、重度反流行介入治疗的疗效分析

目的:探讨膜周部室间隔缺损(VSD)合并三尖瓣中、重度反流行介入治疗的可行性,并评价其疗效.方法:分析2016-01至2017-12我院膜周部VSD合并三尖瓣中、重度反流44例患者,通过应用超声心动图,观察VSD形态、三尖瓣反流程度及原因,评估VSD介入治疗效果及三尖瓣反流在介入术前、术后的变化.结果:43例患者介入治...     

Late tricuspid regurgitation following mitral valve surgery.

The development of late tricuspid regurgitation is an important complication of mitral valve surgery, as it is associated with a severe impairment of exercise capacity and a poor symptomatic outcome. The pathogenesis of this condition remains poorly defined, but it is usually attributable to a functional abnormality of the tricuspid valve. Whilst its development may indicate an increased afterload on the right heart as a consequence of persistent pulmonary hypertension, mitral prosthetic dysfunction, progressive aortic valve disease or left ventricular failure, late tricuspid regurgitation may also develop in the absence of these factors and then may reflect right ventricular dysfunction and/or a localized abnormality of the tricuspid anulus. Failure to recognize and correct tricuspid regurgitation at the time of initial surgery may also account for many cases of tricuspid regurgitation but its re-appearance following tricuspid annuloplasty is uncommon and usually reflects a failure of the mitral prosthesis. A reduction in the prevalence of late tricuspid regurgitation is an important objective in view of the high operative mortality and disappointing long term results associated with reoperation for tricuspid regurgitation. This may be best achieved through combining earlier mitral valve surgery with the accurate detection and liberal correction of accompanying tricuspid incompetence at the time of initial surgery.(ABSTRACT TRUNCATED AT 250 WORDS)     

Severe tricuspid regurgitation due to ventricular pacing lead - a case report

We present a case of severe symptomatic tricuspid valve regurgitation due to shifting of the septal leaflet of the valve toward the interventricular septum by a permanent ventricular pacemaker lead, making coaptation of the tricuspid leflats in systole impossible.     

Morphological Assessment of the Tricuspid Apparatus and Grading Regurgitation Severity in Patients With Functional Tricuspid Regurgitation: Thinking Outside the Box

Current guidelines recommend transthoracic echocardiography to assess patients with functional tricuspid regurgitation (FTR) because it provides information regarding the presence of structural abnormalities of the tricuspid valve (TV), allows measurement of tricuspid annulus diameter, and evaluates severity of FTR by integrating data obtained from 2D and Doppler echocardiography. Critical components of the noninvasive evaluation include information regarding TV anatomy, tricuspid regurgitation severity, right ventricular size and systolic function, and associated findings such as estimated pulmonary artery pressure. However, most of the parameters included in the current recommendations to assess FTR are derived from the experience and knowledge developed about the mitral valve and have been transferred from the left to the right side of the heart without accounting for differences in anatomy of the tricuspid and mitral apparatus or for differences in hemodynamic environment in which the TV operates compared to its left counterpart.     

A case of unguarded tricuspid valve orifice diagnosed accidentally in an adult

Unguarded tricuspid orifice is the most extreme of tricuspid valve dysplasia with a very variable natural history. They can tolerate tricuspid regurgitation well, and they become symptomatic only if significant right ventricular dysfunction or atrial fibrillation occurs. Patients with a mild degree of right ventricular dysfunction can survive to adulthood and even reach old age. Surgical treatment is a difficult option due to variable natural history, and surgical results are not too encouraging.     

Severe tricuspid regurgitation secondary to dislodgement of the atrial loop into the right ventricle: an unusual complication of pacemaker implantation in a young adult

Transvenous pacemaker leads may impair tricuspid valve function. Severe tricuspid regurgitation due to leaflet adhesion to the pacemaker lead has not been reported in a young adult patient in the literature. Our patient underwent a transvenous pacemaker implantation for symptoms of bradycardia. An atrial loop was created in the right atrium for future growth. After 10 years of follow-up, the patient was seen with severe tricuspid regurgitation and enlarged right heart structures due to migration of the atrial loop of the pacemaker lead into the right ventricle and adhesion of the lead to the tricuspid valve. Cardiac surgery and epicardial pacing was the chosen procedure to solve this problem. The venous system and right heart valves should be carefully observed during the follow-up of children who underwent transvenous pacing.     

A new approach to the tricuspid valve in Ebstein's anomaly by real time 3D echocardiography

Ebstein's anomaly affects the tricuspid valve with a large range of anatomical forms. Successful tricuspid valvuloplasty depends mainly on the ability to mobilise the leaflets. Evaluation of the leaflet surface is difficult with 2D echocardiography whereas 3D echocardiography provides intracardiac views of the valve. The authors used this method in 10 patients with 3 modes of imaging: biplane, real time and total volume. The study population (age: 1 day to 30 years) included: 1 prenatal diagnosis, 1 neonate with refractory cyanosis, 5 patients with mild tricuspid regurgitation, 3 patients with severe tricuspid regurgitation, 2 of whom underwent valvuloplasty. 3D echocardiography was disappointing in the foetus and neonate because of poor spatial resolution. The ventricular view of the tricuspid valve in older children and adults allowed analysis of tricuspid leaflet coaptation and of the mechanism of regurgitation. The commissures and leaflet surfaces were assessed. The results of surgical valvuloplasty could be evaluated by 3D echocardiography. 3D echocardiography is now transthoracic and a real time investigation. Technical advances are required before it comes into routine usage: a more manoeuvrable matricial probe (integrating pulsed and continuous wave Doppler) and larger volume real time 3D imaging with better resolution. Its role in the assessment of Ebstein's anomaly should be evaluated in a larger series of patients.     

The importance of tricuspid valve structure and function in the surgical treatment of rheumatic mitral and aortic disease.

A significant proportion of individuals with rheumatic disease have tricuspid valve involvement which may be clinically important and alter the medical or surgical approach to treatment. Therefore 50 patients with rheumatic left-sided valvular lesions who were referred for operative treatment were studied. Thirty patients had angiographically significant tricuspid regurgitation (group I) and 20 had a competent tricuspid valve (group II). Pre-operative cardiac assessment included Doppler echocardiography and contrast ventriculography. Patients with tricuspid regurgitation more commonly had mitral valve disease or combined mitral and aortic valve lesions, (P less than 0.001) and were more likely to have atrial fibrillation than those without tricuspid regurgitation (P less than 0.001). Pulmonary arterial systolic and mean right atrial pressures were higher in group I (both P less than 0.01). A close relationship was found between the angiographic and Doppler assessment of the degree of tricuspid regurgitation (P less than 0.01). Doppler-derived measurement of the right ventricular-right atrial systolic pressure difference correlated well with the systolic trans-tricuspid pressure difference measured at cardiac catheterization (y = 0.7x + 22, r = 0.67, P less than 0.001) and the pulmonary arterial systolic pressure (y = 0.8x + 27, r = 0.71, P less than 0.001). Rheumatic involvement of the tricuspid valve identified by pre-operative echocardiography was confirmed in five patients at surgery. Of the 13 patients with functional tricuspid regurgitation at operation, only two had been diagnosed as having organic disease by echocardiography. Furthermore, in all 18 cases where Doppler suggested grade 3 or 4+ tricuspid regurgitation, surgical repair or replacement of the valve was performed.(ABSTRACT TRUNCATED AT 250 WORDS)     

A new technique: Right ventriculography using a preshaped catheter

Right ventriculography with a preshaped catheter (J- or L-shaped) was evaluated in make the diagnosis of tricuspid regurgitation. Thirty normal subjects who did not have valvular disease showed no evidence of tricuspid regurgitation or premature ventricular contractions during injection except in one case. On the other hand, 24 patients with combined aortic and mitral valve disease showed mild to moderate tricuspid regurgitation in 11 patients and severe tricuspid regurgitation in eight patients. Only two patients developed frequent run of premature ventricular contraction during injection. Seven patients with severe tricuspid regurgitation were found to have severe tricuspid regurgitation during surgery. No evidence of tricuspid regurgitation was found In all six patients with isolated aortic valve disease. We can conclude that right ventriculography by the preshaped catheter improves the diagnostic accuracy of tricuspid regurgitation and a grading system of tricuspid regurgitation by angiography is proposed.     

Flail Tricuspid Valve in an Adult Patient with Congenitally Corrected Transposition of the Great Arteries

We describe a case of a 50-year-old woman with congenitally corrected transposition of the great vessels, in whom severe left-sided tricuspid (systemic atrioventricular) valve insufficiency was the only associated anomaly. The tricuspid valve was dysplastic and abnormally oriented toward the interventricular septum, without the downward displacement of Ebstein's anomaly. The mechanism of atrioventricular regurgitation was unusual in that it consisted of the rupture of chordae tendineae of both the anterior and septal leaflets. The left-sided tricuspid valve was replaced with a St. Jude prosthesis and the postoperative course was uneventful.