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Perforation of the tricuspid leaflet due to pacing wire

EACVI Valvular Imaging Box

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



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

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.

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.

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).