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Perforation of the tricuspid leaflet due to pacing wire

Authors:  Dr. Julia Grapsa, Dr. Michael F Bellamy, Dr. Andreas Kalogeropoulos, Dr. Grigorios Karamasis, Mr. David Dawson, Prof. Petros Nihoyannopoulos.

Hammersmith Hospital
Imperial College NHS Trust

Contact : Julia Grapsa,
EACVI ambassador for Greece

On behalf of the EACVI club 35 for Greece


 

Description

72 years old man with a mitral valve replacement 6 months ago.

He developed complete heart block and required a VVI pacemaker
The patient was admitted with shortness of breath, raised jugular vein pressure and signs of right side heart failure.

Clinical case information

http://www.youtube.com/watch?v=CKAQvhMtLKQ
http://www.youtube.com/watch?v=Aghi9pEZ1zQ
Parasternal long axis: Left ventricle is normal in size with good systolic function. Right ventricle is dilated with volume overload. The prosthetic mitral valve is well seated with no rocking motion. Left atrium is dilated. Apical 4 chamber view focused on the right ventricle : Right ventricle is dilated and hypertrophied with significant volume overload. Right atrium is dilated. There is severe tricuspid regurgitation.

 

http://www.youtube.com/watch?v=AOBFR7d4nP0
Apical 4 chamber view zoomed on the tricuspid valve : On this view, we are able to see the septal tricuspid leaflet (on the right) and either the anterior or the posterior tricuspid leaflet (on the left). It seems that the pacemaker lead has perforated the tricuspid leaflet causing significant restriction of its mobility. Continuous wave Doppler flow across the tricuspid valve : The velocity curve is rather steep which indicates severe tricuspid regurgitation. TR velocity is 2.8 m/sec (PPG 32 mmHg). The Bernoulli equation may be not valid as there is clear perforation of the tricuspid leaflet and free flow tricuspid regurgitation.

 

http://www.youtube.com/watch?v=VzBOP0hoMPw
Real time 3-dimensional echocardiography of the tricuspid valve : It is useful in identifying the anatomy of the tricuspid valve: the pacing lead perforates the tricuspid leaflet (seen at 9 o clock on the short axis).

 

Conclusion

  • Transthoracic echocardiogram demonstrated perforation of tricuspid leaflet and severe tricuspid regurgitation, secondary to the pacing wire insertion.
  • The patient had to undergo surgical operation and repair of the tricuspid valve.
  • His postoperative period was uneventful and his symptoms of heart failure resolved.