Three-dimensional echocardiographic evaluation of severe tricuspid
regurgitation due to leaflet damage by permanent pacing lead
Oswald J. Lee,1 Alex P.W. Lee,2 Micky W.T. Kwok,1 Song Wan 1*
1Division
of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong
Kong, Prince of Wales Hospital, Hong Kong;
2Division
of Cardiology, Department of Medicine & Therapeutics, The Chinese University of
Hong Kong, Prince of Wales Hospital, Hong Kong
#Corresponding
to:
Song Wan, MD, FRCS, FACC
Division of Cardiothoracic Surgery
Prince of Wales Hospital
The Chinese University of Hong Kong
Hong Kong
Tel: 852-2632 2629
Fax: 852-2637 7974
E-mail: swan@cuhk.edu.hk
A 76 year-old woman with recent history of permanent pacemaker insertion presented
with congestive heart failure. Transthoracic echocardiography (TTE) showed mildly impaired
left ventricular function, moderate functional mitral regurgitation, and severe tricuspid
regurgitation. However, the mechanism of pacemaker lead causing severe regurgitation was
not directly visualized on two-dimensional imaging (Figure A). Three-dimensional (3D) TTE
revealed the pacemaker lead was “stuck” to the septal leaflet of tricuspid valve (arrow), raising
the suspicion of pacing lead damage of the valve as the cause of severe regurgitation (Figure B).
Mitral and tricuspid valves repair was performed. Preoperative 3D transesophageal
echocardiography (Figure C) demonstrated clearly the pacemaker lead passed “through” the
body of the tricuspid septal leaflet, hindering its excursion and causing organic regurgitation.
Surgical inspection confirmed the perforation of the tricuspid septal leaflet by the pacemaker
lead (Figure D). The lead was surgically freed from the valve and the leaflet repaired, followed
by a ring annuloplasty. Postoperative echocardiography confirmed competent valve closure
(Figure E). The patient recovered uneventfully. This case illustrated how 3D echocardiographic
imaging was helpful to more clearly delineate the location of the pacemaker lead and its impact
on the tricuspid valve.
Disclosures:
All authors have no conflict of interest.
Figure legends
Figure A: Preoperative two-dimensional transthoracic echocardiography (TTE) imaging.
Figure B: Preoperative three-dimensional (3D) TTE imaging.
Figure C: Preoperative 3D transesophageal echocardiography imaging.
Figure D: Intra-operative surgical finding showed the pacemaker lead perforated the tricuspid
septal leaflet.
Figure E: Postoperative 3D transesophageal echocardiography imaging.
Figure A
Figure B
Figure C
Figure D
Figure E