Download Three-Dimensional Transthoracic Echocardiography

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Cardiovascular
Medicine
Three-Dimensional
Transthoracic
Echocardiography
in the Diagnosis of Device Lead-Related
Tricuspid Leaflet Entrapment
Rajeev L. Narayan, MD
Prashant Vaishnava, MD
Martin Goldman, MD
A
79-year-old man in New York Heart Association functional class II was referred for evaluation because of right-sided heart failure, progressive lowerextremity 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.
A
Section Editor:
Raymond F. Stainback, MD,
Department of Adult
Cardiology, Texas Heart
Institute at St. Luke’s
Episcopal Hospital, 6624
Fannin St., Suite 2480,
Houston, TX 77030
B
From: Department of
Cardiology, Mount Sinai
Heart, Mount Sinai Hospital,
New York, New York 10029
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
© 2012 by the Texas Heart ®
Institute, Houston
906
Tricuspid Leaflet Entrapment
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 cardioverterdefibrillator lead (*), with normal
motion of the anterior (AL) and
septal (SL) leaflets.
Real-time motion image of
Click here for real-time
Figure 1B is available at www.
motion image: Fig. 1B.
texasheart.org/journal.
Volume 39, Number 6, 2012
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 devicerelated 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
Texas Heart Institute Journal
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
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.
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.
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 cardioverterdefibrillator leads. J Am Coll Cardiol 2005;45(10):1672-5.
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.
Tricuspid Leaflet Entrapment
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