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Images and Case Reports in Heart Failure
Pacemaker Lead-Induced Severe Tricuspid Valve Stenosis
Ruben Uijlings, MD; Jolanda Kluin, MD, PhD; Remy Salomonsz, MD, PhD;
Mark Burgmans, MD; Maarten-Jan Cramer, MD, PhD
A
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73-year-old man had a DDD pacemaker implanted in
1991 for symptomatic high-degree atrioventricular
block. Because of atrial lead dysfunction, a new atrial lead
was implanted in 1998. Ten years later, the patient experienced unexplained ascites and edema with progressive exertional dyspnea, for which he was referred. Chest radiography
showed a loop of the ventricular lead at the level of the
tricuspid valve (Figure 1). Transthoracic echocardiography
demonstrated an enlarged right atrium. The mean diastolic
gradient across the tricuspid valve was 15 mm Hg with a peak
pressure drop of 29 mm Hg without tricuspid regurgitation
(Figure 2). No other abnormalities were found. Transesophageal echocardiogram revealed looping of one of atrial leads
at the level of the tricuspid valve but could not visualize the
exact anatomic position of the leads and the cause of the
tricuspid valve stenosis (Figure 3).
A cardiac computed tomography (CT) revealed 2 atrial
leads in the right atrial free wall. However, the ventricular
Figure 1. Chest radiography showed a loop of the ventricular lead at the level of the tricuspid valve.
Received December 1, 2009; accepted February 16, 2010.
From the Departments of Cardiology (R.U., M.J.C.), Cardiothoracic Surgery (J.K.), and Radiology (M.B.), University Medical Centre, Utrecht, The
Netherlands; and Department of Cardiology (R.S.), Ruwaard van Putten Hospital, Spijkenisse, The Netherlands.
Correspondence to Ruben Uijlings, MD, Department of Cardiology, University medical Center, Heidelberglaan 100, 3584 CX Utrecht, The
Netherlands. E-mail [email protected]
(Circ Heart Fail. 2010;3:465-467.)
© 2010 American Heart Association, Inc.
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465
DOI: 10.1161/CIRCHEARTFAILURE.109.928168
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Circ Heart Fail
May 2010
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Figure 2. Transthoracic echocardiography demonstrated severe tricuspid stenosis with a mean diastolic gradient across the tricuspid
valve of 15 mm Hg with a peak pressure drop of 29 mm Hg.
lead entered the ventricle through the tricuspid orifice, looped
back into the atrium, surrounded the atrial leads, and ended in
the apex of the right ventricle (Figure 4).
The CT images showed that the right ventricular lead
finally traversed the tricuspid level near the interventricular
septum. Therefore, we suspected tricuspid valve perforation
with secondary fibrosis. Pacemaker lead-induced severe tricuspid valve stenosis was diagnosed.
At surgery, severe fibrosis with involvement of the valve
leaflets was seen. As shown by CT, the right ventricular lead
looped back from the ventricle into the atrium, then encircled
one atrial lead against the septal leaflet (Figure 5). It was not
sure whether the lead had perforated the septal cusp or the
abundant fibrosis surrounding the lead and tricuspid valve
mimicked valve perforation. The pacemaker leads and the
tricuspid valve were excised, and a porcine bioprosthetic
Figure 3. Transesophageal echocardiogram revealed looping of one of atrial leads at the level of the tricuspid valve.
Uijlings et al
Lead-Induced Severe Tricuspid Valve Stenosis
467
Figure 4. Cardiac CT revealed two atrial leads in the right atrial free wall. The ventricular lead entered the ventricle, looped back into
the atrium, surrounded the atrial leads, and ended in the apex of the right ventricle.
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Figure 5. Perioperative photography and illustrative picture of the surgical view showing the proximal right ventricular lead (blue) entering the right ventricle through the stenosed tricuspid ostium. The distal right ventricular lead looped back into the atrium outside the
tricuspid ostium and encircled one atrial lead before re-entering the right ventricle outside the ostium.
tricuspid valve was implanted. Additionally, epicardial leads
were placed. Histology showed fibrosis without signs of
active endocarditis. Postoperative echocardiography showed
a mean gradient of 4 mm Hg across the bioprothesis without
regurgitation. The patient’s recovery was uneventful; and
within 2 weeks, he had better exercise tolerance.
Severe tricuspid valve stenosis due to pacemaker leads is
uncommon. We present a case of iatrogenic tricuspid valve
stenosis with fibrosis. Tricuspid valve stenoses secondary to
transvenous leads are reported to be treated with surgical
replacement,1,2 surgical valvuloplasty,1 or percutaneous balloon valvuloplasty.3 Cardiac CT can provide supportive
evidence of the anatomic mechanism of valve dysfunction
and planning of treatment strategy.
Acknowledgments
We thank Ingrid Janssen for her technical assistance.
Disclosures
None.
References
1. Heaven DJ, Henein MY, Sutton R. Pacemaker lead related tricuspid stenosis: a report of two cases. Heart. 2000;83:351–352.
2. Krisnan A, Moulick A, Sinha P, Kuehl K, Kanter J, Slack M, Kaltman J,
Mercader M, Moak JP. Severe tricuspid valve stenosis secondary to
pacemaker leads presenting as ascites and liver dysfunction: a complex
problem requiring a multidisciplinary therapeutic approach. J Interv Card
Electrophysiol. 2009;24:71–75.
3. Hussain T, Knight WB, McLeod KA. Lead-induced tricuspid stenosissuccessful management by balloon angioplasty. Pacing Clin Electrophysiol.
2009;32:140–142.
Pacemaker Lead-Induced Severe Tricuspid Valve Stenosis
Ruben Uijlings, Jolanda Kluin, Remy Salomonsz, Mark Burgmans and Maarten-Jan Cramer
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Circ Heart Fail. 2010;3:465-467
doi: 10.1161/CIRCHEARTFAILURE.109.928168
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