Pacemaker Lead-Induced Severe Tricuspid Valve Stenosis
2010; Lippincott Williams & Wilkins; Volume: 3; Issue: 3 Linguagem: Inglês
10.1161/circheartfailure.109.928168
ISSN1941-3297
AutoresRuben Uijlings, Jolanda Kluin, Remy Salomonsz, Mark C. Burgmans, Maarten-Jan Cramer,
Tópico(s)Cardiac Arrhythmias and Treatments
ResumoHomeCirculation: Heart FailureVol. 3, No. 3Pacemaker Lead-Induced Severe Tricuspid Valve Stenosis Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessCase ReportPDF/EPUBPacemaker Lead-Induced Severe Tricuspid Valve Stenosis Ruben Uijlings, MD, Jolanda Kluin, MD, PhD, Remy Salomonsz, MD, PhD, Mark Burgmans, MD and Maarten-Jan Cramer, MD, PhD Ruben UijlingsRuben Uijlings 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. , Jolanda KluinJolanda Kluin 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. , Remy SalomonszRemy Salomonsz 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. , Mark BurgmansMark Burgmans 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. and Maarten-Jan CramerMaarten-Jan Cramer 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. Originally published1 May 2010https://doi.org/10.1161/CIRCHEARTFAILURE.109.928168Circulation: Heart Failure. 2010;3:465–467A 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).Download figureDownload PowerPointFigure 1. Chest radiography showed a loop of the ventricular lead at the level of the tricuspid valve.Download figureDownload PowerPointFigure 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.Download figureDownload PowerPointFigure 3. Transesophageal echocardiogram revealed looping of one of atrial leads at the level of the tricuspid valve.A cardiac computed tomography (CT) revealed 2 atrial leads in the right atrial free wall. However, the ventricular 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).Download figureDownload PowerPointFigure 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.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 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.Download figureDownload PowerPointFigure 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.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.AcknowledgmentsWe thank Ingrid Janssen for her technical assistance.DisclosuresNone.FootnotesCorrespondence to Ruben Uijlings, MD, Department of Cardiology, University medical Center, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands. E-mail r.[email protected]nlReferences1. Heaven DJ, Henein MY, Sutton R. Pacemaker lead related tricuspid stenosis: a report of two cases. Heart. 2000; 83:351–352.CrossrefMedlineGoogle Scholar2. 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.CrossrefMedlineGoogle Scholar3. Hussain T, Knight WB, McLeod KA. Lead-induced tricuspid stenosis-successful management by balloon angioplasty. Pacing Clin Electrophysiol. 2009; 32:140–142.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Lau E (2017) Leads and Electrodes for Cardiac Implantable Electronic Devices Clinical Cardiac Pacing, Defibrillation and Resynchronization Therapy, 10.1016/B978-0-323-37804-8.00011-0, (313-351.e29), . Lau E (2017) Multi-site multi-polar left ventricular pacing through persistent left superior vena cava in tricuspid valve disease, Indian Pacing and Electrophysiology Journal, 10.1016/j.ipej.2017.05.008, 17:5, (156-159), Online publication date: 1-Sep-2017. Chaudesaygues E, Ferrini M and Ritz B (2017) Insuffisance cardiaque par rétrécissement tricuspidien provoqué par une sonde d'électrostimulation. À propos d'un cas, Annales de Cardiologie et d'Angéiologie, 10.1016/j.ancard.2016.09.037, 66:2, (109-111), Online publication date: 1-Apr-2017. De Meester P, Budts W and Gewillig M (2014) Transvenous valve-in-valve replacement preserving the function of a transvalvular defibrillator lead, Catheterization and Cardiovascular Interventions, 10.1002/ccd.25451, 84:7, (1148-1152), Online publication date: 1-Dec-2014. Coffey S, Rayner J, Newton J and Prendergast B (2014) Right-sided valve disease, International Journal of Clinical Practice, 10.1111/ijcp.12485, 68:10, (1221-1226), Online publication date: 1-Oct-2014. Moller J (2012) Right Ventricular Inflow Obstruction Pediatric Cardiovascular Medicine, 10.1002/9781444398786.ch29, (401-405), Online publication date: 10-Feb-2012. May 2010Vol 3, Issue 3 Advertisement Article InformationMetrics © 2010 American Heart Association, Inc.https://doi.org/10.1161/CIRCHEARTFAILURE.109.928168PMID: 20484199 Manuscript receivedDecember 1, 2009Manuscript acceptedFebruary 16, 2010Originally publishedMay 1, 2010 PDF download Advertisement SubjectsCardiovascular SurgeryComputerized Tomography (CT)PacemakerValvular Heart Disease
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