Severe tricuspid valve stenosis secondary to pacemaker leads presenting as ascites and liver dysfunction: a complex problem requiring a multidisciplinary therapeutic approach

Iatrogenic Tricuspid Regurgitation Associated With Pacemakers: A Case Compounded by Tricuspid Stenosis

A patient presented with severe tricuspid regurgitation 20 years after dual-chamber pacing. Transesophageal echocardiography suggested ventricular pacing wire adherence to the tricuspid valve (TV) and atrial wire prolapse across the tricuspid annulus. Surgical extraction of the pacing wires revealed TV commissural fusion and subvalvular thickening causing tricuspid stenosis, requiring TV replacement. (Level of Difficulty: Intermediate.).

[Heart failure provoked by a pacemaker lead-induced tricuspid stenosis]

Tricuspid stenosis (TS) is an uncommon complication of ventricular pacemaker implantation. Mechanisms described by the literature are ventricular inflow obstruction by tricuspid vegetations (endocarditis) or multiple pacemaker leads and fibrosis secondary to mechanical trauma, accounting for perforation or laceration of the TV leaflets, or adherence between redundant loops and valve tissue. We present the case of iatrogenic tricuspid stenosis, observed in a 77-year-old man. Extrinsic tricuspid valve stenosis was detected by transthoracic echocardiography. Further investigations confirmed the intramyocardial lead position. Tricuspid valve stenosis due to transvenous leads are reported to be treated by surgical replacement, surgical valvuloplasty, or percutaneous balloon valvuloplasty.

Percutaneous tricuspid valvotomy for pacemaker lead-induced tricuspid stenosis

Permanent pacemaker lead-induced tricuspid regurgitation is extremely uncommon. We report a patient with severe tricuspid stenosis detected 10 years after permanent single chamber pacemaker implantation in surgically corrected congenital heart disease. The loop at the level of the tricuspid valve may have caused endothelial injury and eventually led to stenosis. Percutaneous balloon valvotomy for such stenosis has not been reported from India.

Acquired Tricuspid Valve Stenosis Associated with Two Ventricular Endocardial Pacing Leads in a Dog

Acquired tricuspid valve stenosis (TVS) is a rare complication of endocardial pacing lead implantation in humans that has only been described once previously in the veterinary literature in a dog with excessive lead redundancy. A 12 yr old terrier presented with right-sided congestive heart failure 6 mo after implantation of a second ventricular endocardial pacing lead. The second lead was placed due to malfunction of the first lead, which demonstrated abnormally low impedance. Transthoracic echocardiography identified hyperechoic tissue associated with the pacing leads as they crossed the tricuspid valve annulus as well as a stenotic tricuspid inflow pattern via spectral Doppler interrogation. Medical management was ultimately unsuccessful and the dog was euthanized 6 wk after TVS was diagnosed. The authors report the first canine case of acquired TVS associated with two ventricular endocardial pacing leads.

Contemporary outcomes of operations for tricuspid valve infective endocarditis

BACKGROUND

Tricuspid valve infective endocarditis (TVIE) is uncommon. Patients are traditionally treated with antibiotics alone, and indications for operation are not clearly established. We report our operative single-center experience.

METHODS

We retrospectively reviewed 56 patients who underwent operations for TVIE between January 2002 and December 2012.

RESULTS

Methicillin-resistant Staphylococcus aureus was present in 41% of patients, septic pulmonary emboli in 63%, moderate/severe tricuspid regurgitation in 66%, and 86% were intravenous drug abusers. Patients underwent early operation if there was concomitant left-sided endocarditis with indications for operation (n = 18), atrial septal defect (n = 6), infected pacemaker lead (n = 4), or prosthetic TVIE (n = 1). The remaining 27 patients were treated with intravenous antibiotics. Five patients completed a 6-week course of intravenous antibiotics before requiring an operation for symptomatic severe tricuspid regurgitation or persistent bacteremia. Twenty-two patients did not complete the antibiotic therapy and underwent operation for symptomatic severe tricuspid regurgitation (n = 15), persistent fevers/bacteremia (n = 3), or patient-specific factors (n = 4). Valve repair was successful in 57% of patients. Overall operative mortality was 7.1%. No operative deaths occurred in patients with isolated native TVIE. Recurrent TVIE was diagnosed in 21% (5 of 24) of the replacement group and in 0% (0 of 32) in the repair group. Use of repair was strongly protective against recurrent TVIE (p < 0.01).

CONCLUSIONS

In contrast to previously published reports of high operative mortality with TVIE, this experience demonstrates improved outcomes with low morbidity and mortality, particularly for native isolated TVIE. Future prospective comparisons between surgically and medically treated patients may help to further define indications and timing for operation for patients with TVIE.

Combined epicardial and transvenous placement of an implantable cardioverter defibrillator (ICD) lead without a median sternotomy in an 8-year-old child

An alternative to median sternotomy for epicardial placement of an implantable cardioverter defibrillator (ICD) lead in a child with hypertrophic cardiomyopathy is described. Implantation of an ICD lead via the tricuspid valve was avoided by the use of an epicardial pacing lead and a transvenous defibrillator lead placed in the vena brachiocephalica. The abdominal, subcostal pocket incision was used for an anterolateral minithoracotomy to implant the epicardial pacing lead.

Model for end-stage liver disease predicts mortality for tricuspid valve surgery

BACKGROUND

Patients undergoing tricuspid valve surgery have a mortality of 9.8%, which is higher than expected given the complexity of the procedure. Despite liver dysfunction seen in many patients with tricuspid disease, no existing risk model accounts for this. The Model for End-Stage Liver Disease (MELD) score accurately predicts mortality for abdominal surgery. The objective of this study was to determine if MELD could accurately predict mortality after tricuspid valve surgery and compare it to existing risk models.

METHODS

From 1994 to 2008, 168 patients (mean age, 61 +/- 14 years; male = 72, female = 96) underwent tricuspid repair (n = 156) or replacement (n = 12). Concomitant operations were performed in 87% (146 of 168). Patients with history of cirrhosis or MELD score 15 or greater (MELD = 3.8*LN [total bilirubin] + 11.2*log normal [international normalized ratio] + 9.6*log normal [creatinine] + 6.4) were compared with patients without liver disease or MELD score less than 15. Preoperative risk, intraoperative findings, and complications including operative mortality were evaluated. Statistical analyses were performed using chi(2), Fisher's exact test, and area under the curve (AUC) analyses.

RESULTS

Patients with a history of liver disease or MELD score of 15 or greater had significantly higher mortality (18.9% [7 of 37] versus 6.1% [8 of 131], p = 0.024). To further characterize the effect of MELD, patients were stratified by MELD alone. No major differences in demographics or operation were identified between groups. Mortality increased as MELD score increased, especially when MELD score of 15 or greater (p = 0.0015). A MELD score less than 10, 10 to 14.9, 15 to 19.9, and more than 20 was associated with operative mortality of 1.9%, 6.8%, 27.3%, and 30.8%, respectively. By multivariate analysis, MELD score of 15 or greater remained strongly associated with mortality (p = 0.0021). The MELD score predicted mortality (AUC = 0.78) as well as the European System for Cardiac Operative Risk Evaluation logistic risk calculator (AUC = 0.78, p = 0.96).

CONCLUSIONS

The MELD score predicts mortality in patients undergoing tricuspid valve surgery and offers a simple and effective method of risk stratification in these patients.