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

1. Unusual Tricuspid
Valve Regurgitation
Claire Cimadevilla MD and
David Messika-Zeitoun MD, PhD
Bichat Hospital, Paris, France

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. Clinical, ECG and Transthoracic Echocardiographic
Examination
• Asymptomatic
• Physical examination
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•
•
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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)
•
•
•
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Enlarged left ventricle
Severely depressed ejection fraction (EF=30%)
Moderate functional mitral regurgitation
Mild tricuspid regurgitation
SPAP 50mmHg
Intra-atrial thrombus

4. 2D Transthoracic Echocardiography
RV
RA
• Apical and subcostal TTE views showing mild tricuspid regurgitation

5. Management and Outcome
• In hospital management
•
•
•
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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. 2D Transthoracic Echocardiography
Watch video

7. 2D Transthoracic Echocardiography
• Severe rightsided chamber
enlargement
• Severe tricuspid
regurgitation
with complete
lack of
coaptation
Apical 4 chamber view

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. 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. 3D Transoesophageal Echocardiography
Watch vidéo

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. Diagnosis
Iatrogenic « functional »
tricuspid regurgitation due to
the pace maker lead

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. 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. 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. Join the ESC Working Group
on Valvular Heart Disease
and take part in its
activities !
Membership is FREE!