Unusual Tricuspid Valve Regurgitation

Claire Cimadevilla MD and David Messika-Zeitoun MD, PhD Bichat Hospital, Paris, France

Medical History

• 75 year old man

• HIV (antiretroviral therapy)

• Severe chronic kidney disease(dialysis)

• Ischaemic cardiomyopathy : past myocardial infarction 1991

• Admitted in January 2013 with atrio-ventricular block for pacemaker implantation

Clinical, ECG and Transthoracic Echocardiographic Examination

• Asymptomatic

• Physical examination• BP 90/50mmHg• HR 45 beat / min• No signs of congestive heart failure• No murmur

• ECG : atrial fibrillation, QRS duration 120ms

• Echocardiography (transthoracic and transoesophageal)• Enlarged left ventricle• Severely depressed ejection fraction (EF=30%)• Moderate functional mitral regurgitation • Mild tricuspid regurgitation• SPAP 50mmHg • Intra-atrial thrombus

2D Transthoracic Echocardiography

• Apical and subcostal TTE views showing mild tricuspid regurgitation

RA

RV

Management and Outcome

• In hospital management• CRT + ICD implantation • Anticoagulation (Antivitamin K)• No cardioversion (intra-atrial thrombus)• Discharged home without complication

• 06/2013 : hospitalisation for electrical cardioversion• NYHA III• Physical examination

• BP 85/50mmHg, HR 70 bpm• 2/6 systolic murmur• Severe right congestive heart failure (jugular venous distension, ankle oedema)• No sign of general or local infection

• ECG : AF, ventricular stimulation

2D Transthoracic Echocardiography

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2D Transthoracic Echocardiography

• Severe right-sided chamber enlargement

• Severe tricuspid regurgitation with complete lack of coaptation

Apical 4 chamber view

What is your diagnosis?

1.Rheumatic TR

2.Organic TR due to flail leaflet

3.Functional TR due to severe left side-disease

4.Functional TR due to the PM lead

5.Tricuspid endocarditis secondary to PM implantation

What is your diagnosis?

1.Rheumatic TR

2.Organic TR due to flail leaflet

3.Functional TR due to severe left side-disease

4.Functional TR due to the PM lead

5.Tricuspid endocarditis secondary to PM implantation

3D Transoesophageal Echocardiography

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3D Transoesophageal Echocardiography

3D TOE : The PM lead impedes normal closure of the tricuspid valve and is responsible for severe TR. Note that the posterior leaflet is immobile.

PM leadPM lead

The 3 tricuspid valve leaflets

Posterior leaflet

Right ventricular view

Diagnosis

Iatrogenic « functional » tricuspid regurgitation due to the pace maker lead

PACE MAKER INDUCED TR

• Mild or moderate TR is frequently observed after PM implantation (1-2): the lead is almost always responsible for some degree of incomplete coaptation. Degree of TR increases with the number of leads crossing the tricuspid orifice

• Mechanisms for PM induced TR are multiple:• Traumatic TR after PM implantation or removal (leaflet perforation, flail

tricuspid leaflets)• Adherence between the lead and tricuspid leaflets• Incomplete closure of the tricuspid leaflets (restriction of leaflet motion

due to the lead as in our patient)

1. Increased Prevalence of Significant Tricuspid Regurgitation in Patients with Transvenous Pacemakers leads, Paniagua et Al., The American Journal of Cardiology 1998, 82 Nov1

2. The Effect of Transvenous Pacemaker and Implantable Cardioverter Defibrillator Lead Placement on Tricuspid Valve Function: An Observational Study, Kim et Al, JASE 2008, 21-3

3. Severe Symptomatic Tricuspid Valve Regurgitation Due to Permanent Pacemaker or Implantable Cardioverter-Defibrillator Leads, Lin et Al., JACC 2005, 45-10

PACE MAKER INDUCED TR

• TTE should be performed before and after PM implantation

• TOE may be performed for severe TR in order to identify the mechanism

• In cases of severe symptomatic tricuspid regurgitation caused by the PM lead, percutaneous or surgical material extraction with tricuspid valve repair or replacement should be discussed, depending on TR mechanism

Guidelines on the management of valvular heart disease (version 2012), Vahanian et Al., European Heart Journal

TAKE HOME MESSAGES

• Lead-induced severe tricuspid regurgitation is a rare but severe complication of pacemaker implantation

• TTE should be systematically performed before and after PM implantation

• Percutaneous or surgical material extraction with tricuspid valve repair or replacement should be discussed in cases of severe symptomatic tricuspid regurgitation caused by the PM

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