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Transvenous endocardial right ventricular pacing in a case with prosthetic tricuspid valve
G Model IHJCCR-57; No. of Pages 2
ARTICLE IN PRESS IHJ Cardiovascular Case Reports (CVCR) xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
IHJ Cardiovascular Case Reports (CVCR) journal homepage: www.elsevier.com/locate/ihjccr
Case Report
Transvenous endocardial right ventricular pacing in a case with prosthetic tricuspid valve Rajesh Vijayvergiya ∗ , Ankush Gupta, Sandeep S. Rana Department of Cardiology and Cardiac Surgery, Advanced Cardiac Centre, Post Graduate Institute of Medical Education & Research, Sector 12, Chandigarh-160012, India
a r t i c l e
i n f o
Article history: Received 3 January 2017 Received in revised form 11 October 2017 Accepted 23 October 2017 Available online xxx Keywords: Complete heart block Endocardial pacing Prosthetic tricuspid valve Right ventricular pacing
a b s t r a c t An alternate site pacing is preferred over a standard right ventricular (RV) transvenous endocardial pacing in a patient with prosthetic tricuspid valve, as later may result in valve or pacing lead malfunction. We hereby report a female who had favorable 5-years outcome following endocardial RV pacing through a prosthetic tricuspid valve. © 2017 Cardiological Society of India. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction Transvenous endocardial right ventricular (RV) pacing is relatively contraindicated in a patient with prosthetic tricuspid valve, as there is a possibility of lead or prosthetic valve malfunction following permanent pacing. In such situations, an alternate site pacing is preferred instead of right ventricular pacing. We hereby report a case of bioprosthetic tricuspid valve, who had favorable long term outcome following transvenous endocardial RV permanent pacing. 2. Case report A 65-years old female, who had mitral bio-prosthetic valve replacement with tricuspid valve repair for underlying rheumatic heart disease 10 years back, presented with significant systemic venous congestion following severe tricuspid regurgitation. She underwent bio-prosthetic tricuspid valve replacement (Hancock II stented tissue valve, Medtronic Inc, Minneapolis, Minnesota, US) for severe tricuspid regurgitation. She had an additional permanent endocardial permanent pacemaker implantation (VVI mode, Sensia SES01 model, Medtronic Inc.) for persistent complete heart block, on day 10th following valve surgery. A tined ventricular lead was placed in right ventricle through prosthetic tricuspid valve (Fig. 1),
∗ Corresponding author. E-mail address: [email protected] (R. Vijayvergiya).
Fig. 1. Transvenous endocardial right ventricular (RV) pacing through bioprosthetic tricuspid valve on fluoroscopic examination.
and satisfactory pacing parameters were achieved. She was asymptomatic at 5-years of follow-up, ventricular pacing threshold was 0.75 V at pulse width of 0.40 ms. A 2-dimensitional trans-thoracic echocardiography showed normal functioning tricuspid (Fig. 2A) and mitral prosthetic valves. A peak/mean trans-tricuspid valve diastolic gradient was 9/4 mmHg, and a mild tricuspid regurgitation (Fig. 2B) had peak pressure gradient of 26 mmHg. Prosthetic
https://doi.org/10.1016/j.ihjccr.2017.10.005 2468-600X/© 2017 Cardiological Society of India. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Please cite this article in press as: Vijayvergiya R, et al, Transvenous endocardial right ventricular pacing in a case with prosthetic tricuspid valve, IHJ Cardiovasc Case Rep. (2017), https://doi.org/10.1016/j.ihjccr.2017.10.005
G Model IHJCCR-57; No. of Pages 2
ARTICLE IN PRESS R. Vijayvergiya et al. / IHJ Cardiovascular Case Reports (CVCR) xxx (2017) xxx–xxx
2
Fig. 2. Two-dimensional echocardiography in apical four chamber view showing (A) prosthetic tricuspid valve. (B) Color Doppler across prosthetic tricuspid valve showing mild tricuspid regurgitation. Abbreviations- RA – right atrium, LA – Left atrium.
mitral valve has a peak/mean diastolic gradient of 16/6 mmHg, and no mitral regurgitation. 3. Discussion Transvenous endocardial RV pacing is contraindicated in patients with mechanical tricuspid valve because of concern about damage to endocardial lead or mechanical valve leaflets. Various authors had tried putting pacing leads via coronary sinus, endocardial left ventricular pacing or epicardial pacing in such situation.1,2,3 Those patients with bio-prosthetic tricuspid valve, an endocardial right ventricle lead can be implanted,4,5 as was performed in index case. There is an advantage of stability and durable long term pacing with endocardial RV pacing compared to other site pacing, hence we preferred the standard RV pacing. Mild regurgitation of a native tricuspid valve is frequent noticed on echocardiography following RV pacing,6 hence the same in index case does not have much clinical significance at 5-years of follow-up. However, further echocardiographic follow-up is required for progression of tricuspid regurgitation which can be secondary to degeneration of bioprosthetic valve7 or damage by endocardial lead.6 In conclusion, endocardial RV pacing is still an option in patient with bioprosthetic tricuspid valve, which is otherwise contraindicated with mechanical tricuspid valve prosthesis.
Acknowledgments There is no funding from any agency or institution was taken for this manuscript. There is no conflict of interest of any of the authors. References 1. Winter J, Gramsch-Zabel H, Fürst G, Koch JA, Zimmermann N, Gams E. Long-term follow-up of left ventricular pacing via a posterior cardiac vein after mechanical tricuspid valve replacement. Pacing Clin Electrophysiol. 2001;24:125–126. 2. Ak K, Isbir S, C¸inc¸in A, Kararmaz A, Arsan S. Direct transapical implantation of an endocardial pacing lead to the left ventricle: an alternate pacing site after tricuspid valve replacement. J Card Surg. 2014;29:290–292. 3. Ricciardi D, de Asmundis C, Czapla J, La Meir M, Brugada P, Wellens F. Complete epicardial resynchronization device implantation in a patient who underwent a replacement of mitral and tricuspid valve. Pacing Clin Electrophysiol. 2013;36:e56–8. 4. Pernenkil R, Wright JS. Endocardial pacing through a prosthetic tricuspid valve. Pacing Clin Electrophysiol. 1990;13:1365–1366. 5. Antonelli D, Freedberg NA. Endocardial ventricular pacing through a bioprosthetic tricuspid valve. Pacing Clin Electrophysiol. 2007;30:271–272. 6. Lee RC, Friedman SE, Kono AT, Greenberg ML, Palac RT. Tricuspid regurgitation following implantation of endocardial leads: incidence and predictors. Pacing Clin Electrophysiol. 2015;38:1267–1274. 7. Kaplan M, Kut MS, Demirtas MM, Cimen S, Ozler A. Prosthetic replacement of tricuspid valve: bioprosthetic or mechanical. Ann Thorac Surg. 2002;73:467–473.
Conflict of interest None.
Please cite this article in press as: Vijayvergiya R, et al, Transvenous endocardial right ventricular pacing in a case with prosthetic tricuspid valve, IHJ Cardiovasc Case Rep. (2017), https://doi.org/10.1016/j.ihjccr.2017.10.005
ARTICLE IN PRESS IHJ Cardiovascular Case Reports (CVCR) xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
IHJ Cardiovascular Case Reports (CVCR) journal homepage: www.elsevier.com/locate/ihjccr
Case Report
Transvenous endocardial right ventricular pacing in a case with prosthetic tricuspid valve Rajesh Vijayvergiya ∗ , Ankush Gupta, Sandeep S. Rana Department of Cardiology and Cardiac Surgery, Advanced Cardiac Centre, Post Graduate Institute of Medical Education & Research, Sector 12, Chandigarh-160012, India
a r t i c l e
i n f o
Article history: Received 3 January 2017 Received in revised form 11 October 2017 Accepted 23 October 2017 Available online xxx Keywords: Complete heart block Endocardial pacing Prosthetic tricuspid valve Right ventricular pacing
a b s t r a c t An alternate site pacing is preferred over a standard right ventricular (RV) transvenous endocardial pacing in a patient with prosthetic tricuspid valve, as later may result in valve or pacing lead malfunction. We hereby report a female who had favorable 5-years outcome following endocardial RV pacing through a prosthetic tricuspid valve. © 2017 Cardiological Society of India. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction Transvenous endocardial right ventricular (RV) pacing is relatively contraindicated in a patient with prosthetic tricuspid valve, as there is a possibility of lead or prosthetic valve malfunction following permanent pacing. In such situations, an alternate site pacing is preferred instead of right ventricular pacing. We hereby report a case of bioprosthetic tricuspid valve, who had favorable long term outcome following transvenous endocardial RV permanent pacing. 2. Case report A 65-years old female, who had mitral bio-prosthetic valve replacement with tricuspid valve repair for underlying rheumatic heart disease 10 years back, presented with significant systemic venous congestion following severe tricuspid regurgitation. She underwent bio-prosthetic tricuspid valve replacement (Hancock II stented tissue valve, Medtronic Inc, Minneapolis, Minnesota, US) for severe tricuspid regurgitation. She had an additional permanent endocardial permanent pacemaker implantation (VVI mode, Sensia SES01 model, Medtronic Inc.) for persistent complete heart block, on day 10th following valve surgery. A tined ventricular lead was placed in right ventricle through prosthetic tricuspid valve (Fig. 1),
∗ Corresponding author. E-mail address: [email protected] (R. Vijayvergiya).
Fig. 1. Transvenous endocardial right ventricular (RV) pacing through bioprosthetic tricuspid valve on fluoroscopic examination.
and satisfactory pacing parameters were achieved. She was asymptomatic at 5-years of follow-up, ventricular pacing threshold was 0.75 V at pulse width of 0.40 ms. A 2-dimensitional trans-thoracic echocardiography showed normal functioning tricuspid (Fig. 2A) and mitral prosthetic valves. A peak/mean trans-tricuspid valve diastolic gradient was 9/4 mmHg, and a mild tricuspid regurgitation (Fig. 2B) had peak pressure gradient of 26 mmHg. Prosthetic
https://doi.org/10.1016/j.ihjccr.2017.10.005 2468-600X/© 2017 Cardiological Society of India. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Please cite this article in press as: Vijayvergiya R, et al, Transvenous endocardial right ventricular pacing in a case with prosthetic tricuspid valve, IHJ Cardiovasc Case Rep. (2017), https://doi.org/10.1016/j.ihjccr.2017.10.005
G Model IHJCCR-57; No. of Pages 2
ARTICLE IN PRESS R. Vijayvergiya et al. / IHJ Cardiovascular Case Reports (CVCR) xxx (2017) xxx–xxx
2
Fig. 2. Two-dimensional echocardiography in apical four chamber view showing (A) prosthetic tricuspid valve. (B) Color Doppler across prosthetic tricuspid valve showing mild tricuspid regurgitation. Abbreviations- RA – right atrium, LA – Left atrium.
mitral valve has a peak/mean diastolic gradient of 16/6 mmHg, and no mitral regurgitation. 3. Discussion Transvenous endocardial RV pacing is contraindicated in patients with mechanical tricuspid valve because of concern about damage to endocardial lead or mechanical valve leaflets. Various authors had tried putting pacing leads via coronary sinus, endocardial left ventricular pacing or epicardial pacing in such situation.1,2,3 Those patients with bio-prosthetic tricuspid valve, an endocardial right ventricle lead can be implanted,4,5 as was performed in index case. There is an advantage of stability and durable long term pacing with endocardial RV pacing compared to other site pacing, hence we preferred the standard RV pacing. Mild regurgitation of a native tricuspid valve is frequent noticed on echocardiography following RV pacing,6 hence the same in index case does not have much clinical significance at 5-years of follow-up. However, further echocardiographic follow-up is required for progression of tricuspid regurgitation which can be secondary to degeneration of bioprosthetic valve7 or damage by endocardial lead.6 In conclusion, endocardial RV pacing is still an option in patient with bioprosthetic tricuspid valve, which is otherwise contraindicated with mechanical tricuspid valve prosthesis.
Acknowledgments There is no funding from any agency or institution was taken for this manuscript. There is no conflict of interest of any of the authors. References 1. Winter J, Gramsch-Zabel H, Fürst G, Koch JA, Zimmermann N, Gams E. Long-term follow-up of left ventricular pacing via a posterior cardiac vein after mechanical tricuspid valve replacement. Pacing Clin Electrophysiol. 2001;24:125–126. 2. Ak K, Isbir S, C¸inc¸in A, Kararmaz A, Arsan S. Direct transapical implantation of an endocardial pacing lead to the left ventricle: an alternate pacing site after tricuspid valve replacement. J Card Surg. 2014;29:290–292. 3. Ricciardi D, de Asmundis C, Czapla J, La Meir M, Brugada P, Wellens F. Complete epicardial resynchronization device implantation in a patient who underwent a replacement of mitral and tricuspid valve. Pacing Clin Electrophysiol. 2013;36:e56–8. 4. Pernenkil R, Wright JS. Endocardial pacing through a prosthetic tricuspid valve. Pacing Clin Electrophysiol. 1990;13:1365–1366. 5. Antonelli D, Freedberg NA. Endocardial ventricular pacing through a bioprosthetic tricuspid valve. Pacing Clin Electrophysiol. 2007;30:271–272. 6. Lee RC, Friedman SE, Kono AT, Greenberg ML, Palac RT. Tricuspid regurgitation following implantation of endocardial leads: incidence and predictors. Pacing Clin Electrophysiol. 2015;38:1267–1274. 7. Kaplan M, Kut MS, Demirtas MM, Cimen S, Ozler A. Prosthetic replacement of tricuspid valve: bioprosthetic or mechanical. Ann Thorac Surg. 2002;73:467–473.
Conflict of interest None.
Please cite this article in press as: Vijayvergiya R, et al, Transvenous endocardial right ventricular pacing in a case with prosthetic tricuspid valve, IHJ Cardiovasc Case Rep. (2017), https://doi.org/10.1016/j.ihjccr.2017.10.005