Unusual Tricuspid Valve Regurgitation

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Claire Cimadevilla MD and
David Messika-Zeitoun MD, PhD Bichat Hospital, Paris, France

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Unusual Tricuspid Valve Regurgitation

  1. 1. Unusual Tricuspid Valve Regurgitation Claire Cimadevilla MD and David Messika-Zeitoun MD, PhD Bichat Hospital, Paris, France
  2. 2. Medical History • 75 year old man • HIV (antiretroviral therapy) • Severe chronic kidney disease(dialysis) • Ischaemic cardiomyopathy : past myocardial infarction 1991 • Admitted in January 2013 with atrio-ventricular block for pacemaker implantation
  3. 3. Clinical, ECG and Transthoracic Echocardiographic Examination • Asymptomatic • Physical examination • • • • BP 90/50mmHg HR 45 beat / min No signs of congestive heart failure No murmur • ECG : atrial fibrillation, QRS duration 120ms • Echocardiography (transthoracic and transoesophageal) • • • • • • Enlarged left ventricle Severely depressed ejection fraction (EF=30%) Moderate functional mitral regurgitation Mild tricuspid regurgitation SPAP 50mmHg Intra-atrial thrombus
  4. 4. 2D Transthoracic Echocardiography RV RA • Apical and subcostal TTE views showing mild tricuspid regurgitation
  5. 5. Management and Outcome • In hospital management • • • • CRT + ICD implantation Anticoagulation (Antivitamin K) No cardioversion (intra-atrial thrombus) Discharged home without complication • 06/2013 : hospitalisation for electrical cardioversion • NYHA III • Physical examination • • • • BP 85/50mmHg, HR 70 bpm 2/6 systolic murmur Severe right congestive heart failure (jugular venous distension, ankle oedema) No sign of general or local infection • ECG : AF, ventricular stimulation
  6. 6. 2D Transthoracic Echocardiography Watch video
  7. 7. 2D Transthoracic Echocardiography • Severe rightsided chamber enlargement • Severe tricuspid regurgitation with complete lack of coaptation Apical 4 chamber view
  8. 8. What is your diagnosis? 1.Rheumatic TR 2.Organic TR due to flail leaflet 3.Functional TR due to severe left side-disease 4.Functional TR due to the PM lead 5.Tricuspid endocarditis secondary to PM implantation
  9. 9. What is your diagnosis? 1.Rheumatic TR 2.Organic TR due to flail leaflet 3.Functional TR due to severe left side-disease 4.Functional TR due to the PM lead 5.Tricuspid endocarditis secondary to PM implantation
  10. 10. 3D Transoesophageal Echocardiography Watch vidéo
  11. 11. 3D Transoesophageal Echocardiography Right ventricular view PM lead PM lead Posterior leaflet The 3 tricuspid valve leaflets 3D TOE : The PM lead impedes normal closure of the tricuspid valve and is responsible for severe TR. Note that the posterior leaflet is immobile.
  12. 12. Diagnosis Iatrogenic « functional » tricuspid regurgitation due to the pace maker lead
  13. 13. PACE MAKER INDUCED TR • Mild or moderate TR is frequently observed after PM implantation (1-2): the lead is almost always responsible for some degree of incomplete coaptation. Degree of TR increases with the number of leads crossing the tricuspid orifice • Mechanisms for PM induced TR are multiple: • Traumatic TR after PM implantation or removal (leaflet perforation, flail tricuspid leaflets) • Adherence between the lead and tricuspid leaflets • Incomplete closure of the tricuspid leaflets (restriction of leaflet motion due to the lead as in our patient) 1. 2. 3. Increased Prevalence of Significant Tricuspid Regurgitation in Patients with Transvenous Pacemakers leads, Paniagua et Al., The American Journal of Cardiology 1998, 82 Nov1 The Effect of Transvenous Pacemaker and Implantable Cardioverter Defibrillator Lead Placement on Tricuspid Valve Function: An Observational Study, Kim et Al, JASE 2008, 21-3 Severe Symptomatic Tricuspid Valve Regurgitation Due to Permanent Pacemaker or Implantable Cardioverter-Defibrillator Leads, Lin et Al., JACC 2005, 45-10
  14. 14. PACE MAKER INDUCED TR • TTE should be performed before and after PM implantation • TOE may be performed for severe TR in order to identify the mechanism • In cases of severe symptomatic tricuspid regurgitation caused by the PM lead, percutaneous or surgical material extraction with tricuspid valve repair or replacement should be discussed, depending on TR mechanism Guidelines on the management of valvular heart disease (version 2012), Vahanian et Al., European Heart Journal
  15. 15. TAKE HOME MESSAGES • Lead-induced severe tricuspid regurgitation is a rare but severe complication of pacemaker implantation • TTE should be systematically performed before and after PM implantation • Percutaneous or surgical material extraction with tricuspid valve repair or replacement should be discussed in cases of severe symptomatic tricuspid regurgitation caused by the PM
  16. 16. Join the ESC Working Group on Valvular Heart Disease and take part in its activities ! Membership is FREE!

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