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Tricuspid valve chordae rupture following pacemaker electrode replacement
International Journal of Cardiology 87 (2003) 291–292 www.elsevier.com / locate / ijcard
Letter to the Editor
Tricuspid valve chordae rupture following pacemaker electrode replacement ´ Moreno*, Jose´ Zamorano, Ana Ortega, Alexis Villate, Carlos Almerıa, ´ Dionisio Herrera, Raul ´ Jose-Luis Rodrigo, Ricardo Morales, Luis Sanchez-Harguindey ´ San Carlos, Martin Lagos, s /n, 28040 Madrid, Spain Laboratory of Echocardiography, Instituto Cardiovascular, Hospital Clınico Received 20 January 2002; accepted 14 May 2002
Rupture of tricuspid valve chordae is a very rare entity, non-penetrating chest trauma being its most common cause [1–6]. Additionally, some cases of tricuspid chordae rupture secondary to right-sided catheterization, such as Swan-Ganz catheterization [7] or endomyocardial biopsy [8], have been described. We report a patient in whom a tricuspid valve chordae rupture following definitive pacemaker implantation was documented by transthoracic echocardiography. A 75-year-old female patient was referred to our Echocardiography Laboratory. She had undergone a dual-chamber pacemaker implantation due to complete heart block 11 years ago. Additionally, she had a mild–moderate mitral stenosis diagnosed at least 15 years before. Due to battery failure, she underwent a pacemaker replacement. In this procedure, both atrial and ventricular electrodes were also replaced. An echocardiographic study was carried out prior to pacemaker replacement, showing a mitral valve area of 1.6 cm 2 , with mild tricuspid insufficiency and a systolic pulmonary pressure of 38 mmHg. A transthoracic echocardiographic study performed after pacemaker replacement showed a severe tricuspid regurgitation. A ruptured tricuspid valve chordae with severe tricuspid regurgitation could be *Corresponding author. Tel.: 134-91-330-3283. E-mail address: [email protected] (R. Moreno).
documented (Fig. 1). Systolic pulmonary pressure in this study was similar to that prior to pacemaker replacement. Tricuspid valve tendinae chordae rupture is a very uncommon entity [1–8]. The most frequent cause is blunt chest trauma [1–6], but some cases have been described in relation to right-sided cardiac catheterization procedures [7,8]. We have described a patient with a tricuspid chordae rupture after pacemaker electrode replacement. Tricuspid insufficiency was only mild prior to pacemaker replacement. Additionally, taking into account that she had no history of blunt chest trauma or other potential causes of tricuspid chordae rupture, this finding was attributed to pacemaker replacement. Res et al. described one patient in whom a partial rupture of the tricuspid valve occurred during removal of an entrapped pacemaker electrode in the tricuspid valve chordae [9]. Rajs had previously described at necropsy the presence of tricuspid chordae tendinae rupture that have been clinically unrecognized [10]. Similarly, tricuspid valve chordae rupture that occur after blunt chest trauma may be clinically silent and therefore unrecognized even during several years after trauma [1,6]. In contrast, some poorly tolerated cases have also been described [4]. In the case we have presented, the diagnosis of tricuspid valve rupture was also clinically unsuspected. However, a high quality transthoracic echocardiographic study allowed us to recognize this complication.
0167-5273 / 02 / $ – see front matter 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S0167-5273( 02 )00313-3
292
R. Moreno et al. / International Journal of Cardiology 87 (2003) 291–292
It could be speculated that this complication, although surely uncommon, could be more frequent than diagnosed. Thus, in patients with significant tricuspid insufficiency after pacemaker implantation, a high quality echocardiographic study should be carried out.
References [1] van Son JA, Danielson GK, Schaff HV, Miller Jr. FA. Traumatic tricuspid valve insufficiency. Experience in thirteen patients. J Thorac Cardiovasc Surg 1994;108:893–8. ´ ´ [2] Naja I, Barriuso C, Minot S et al. Rotura traumatica de la valvula ´ ´ tricuspide. Tratamiento quirurgico conservador. Rev Esp Cardiol 1992;45:64–6. [3] Maisano F, Lorusso R, Sandrelli L et al. Valve repair for traumatic tricuspid regurgitation. Eur J Cardiothorac Surg 1996;10:867–73. [4] Bolinger BS, Winslow TM. Transesophageal echocardiographic diagnosis of a ruptured tricuspid valve chordae as the etiology for cardiogenic shock. Chest 1994;105:1286–8. [5] Kleikamp G, Schnepper U, Kortke H, Breymann T, Korfer R. Tricuspid valve regurgitation following blunt thoracic trauma. Chest 1992;102:1294–6. ˜ [6] Oliver JM, Garcia F, Sotillo JF, Benito F, Nunez L, Gil M. ´ ´ ´ Diagnostico etiologico y anatomico de rotura de cuerda tendinosa ´ ´ mediante ecocardiografıa transtoracica. Rev Esp Cardiol 1982;35:39–44. [7] Smith WR, Glauser FL, Jemison P. Ruptured chordae of the tricuspid valve. The consequence of flow-directed Swan-Ganz catheterization. Chest 1976;70:790–2. [8] Braverman AC, Coplen SE, Mudge GH, Lee RT. Ruptured chordae tendinae of the tricuspid valve as a complication of endomyocardial biopsy in heart transplantation. Am J Cardiol 1990;66:111–3. [9] Res JC, De Cock CC, Van Rossum AC, Schreuder J. Entrapment of tined leads. Pacing Clin Electrophysiol 1989;12:1583–5. [10] Rajs J. Postmortem finding and possible causes of unexpected death in patients treated with intraventricular pacing. Pacing Clin Electrophysiol 1983;6:751–60.
Fig. 1. (A) Transthoracic echocardiographic study showing a severe tricuspid regurgitation (apical four-chamber view). (B) Parasternal short axis view showing a ruptured tricuspid tendinae chordae (arrow). (C) Paraesternal short axis view, showing the ruptured tricuspid tendinae chordae higher depth (arrow). RV, right ventricle; RA, right atrium; LV, left ventricle; LA, left atrium; TV, tricuspid valve; PM, pacemaker lead.
Letter to the Editor
Tricuspid valve chordae rupture following pacemaker electrode replacement ´ Moreno*, Jose´ Zamorano, Ana Ortega, Alexis Villate, Carlos Almerıa, ´ Dionisio Herrera, Raul ´ Jose-Luis Rodrigo, Ricardo Morales, Luis Sanchez-Harguindey ´ San Carlos, Martin Lagos, s /n, 28040 Madrid, Spain Laboratory of Echocardiography, Instituto Cardiovascular, Hospital Clınico Received 20 January 2002; accepted 14 May 2002
Rupture of tricuspid valve chordae is a very rare entity, non-penetrating chest trauma being its most common cause [1–6]. Additionally, some cases of tricuspid chordae rupture secondary to right-sided catheterization, such as Swan-Ganz catheterization [7] or endomyocardial biopsy [8], have been described. We report a patient in whom a tricuspid valve chordae rupture following definitive pacemaker implantation was documented by transthoracic echocardiography. A 75-year-old female patient was referred to our Echocardiography Laboratory. She had undergone a dual-chamber pacemaker implantation due to complete heart block 11 years ago. Additionally, she had a mild–moderate mitral stenosis diagnosed at least 15 years before. Due to battery failure, she underwent a pacemaker replacement. In this procedure, both atrial and ventricular electrodes were also replaced. An echocardiographic study was carried out prior to pacemaker replacement, showing a mitral valve area of 1.6 cm 2 , with mild tricuspid insufficiency and a systolic pulmonary pressure of 38 mmHg. A transthoracic echocardiographic study performed after pacemaker replacement showed a severe tricuspid regurgitation. A ruptured tricuspid valve chordae with severe tricuspid regurgitation could be *Corresponding author. Tel.: 134-91-330-3283. E-mail address: [email protected] (R. Moreno).
documented (Fig. 1). Systolic pulmonary pressure in this study was similar to that prior to pacemaker replacement. Tricuspid valve tendinae chordae rupture is a very uncommon entity [1–8]. The most frequent cause is blunt chest trauma [1–6], but some cases have been described in relation to right-sided cardiac catheterization procedures [7,8]. We have described a patient with a tricuspid chordae rupture after pacemaker electrode replacement. Tricuspid insufficiency was only mild prior to pacemaker replacement. Additionally, taking into account that she had no history of blunt chest trauma or other potential causes of tricuspid chordae rupture, this finding was attributed to pacemaker replacement. Res et al. described one patient in whom a partial rupture of the tricuspid valve occurred during removal of an entrapped pacemaker electrode in the tricuspid valve chordae [9]. Rajs had previously described at necropsy the presence of tricuspid chordae tendinae rupture that have been clinically unrecognized [10]. Similarly, tricuspid valve chordae rupture that occur after blunt chest trauma may be clinically silent and therefore unrecognized even during several years after trauma [1,6]. In contrast, some poorly tolerated cases have also been described [4]. In the case we have presented, the diagnosis of tricuspid valve rupture was also clinically unsuspected. However, a high quality transthoracic echocardiographic study allowed us to recognize this complication.
0167-5273 / 02 / $ – see front matter 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S0167-5273( 02 )00313-3
292
R. Moreno et al. / International Journal of Cardiology 87 (2003) 291–292
It could be speculated that this complication, although surely uncommon, could be more frequent than diagnosed. Thus, in patients with significant tricuspid insufficiency after pacemaker implantation, a high quality echocardiographic study should be carried out.
References [1] van Son JA, Danielson GK, Schaff HV, Miller Jr. FA. Traumatic tricuspid valve insufficiency. Experience in thirteen patients. J Thorac Cardiovasc Surg 1994;108:893–8. ´ ´ [2] Naja I, Barriuso C, Minot S et al. Rotura traumatica de la valvula ´ ´ tricuspide. Tratamiento quirurgico conservador. Rev Esp Cardiol 1992;45:64–6. [3] Maisano F, Lorusso R, Sandrelli L et al. Valve repair for traumatic tricuspid regurgitation. Eur J Cardiothorac Surg 1996;10:867–73. [4] Bolinger BS, Winslow TM. Transesophageal echocardiographic diagnosis of a ruptured tricuspid valve chordae as the etiology for cardiogenic shock. Chest 1994;105:1286–8. [5] Kleikamp G, Schnepper U, Kortke H, Breymann T, Korfer R. Tricuspid valve regurgitation following blunt thoracic trauma. Chest 1992;102:1294–6. ˜ [6] Oliver JM, Garcia F, Sotillo JF, Benito F, Nunez L, Gil M. ´ ´ ´ Diagnostico etiologico y anatomico de rotura de cuerda tendinosa ´ ´ mediante ecocardiografıa transtoracica. Rev Esp Cardiol 1982;35:39–44. [7] Smith WR, Glauser FL, Jemison P. Ruptured chordae of the tricuspid valve. The consequence of flow-directed Swan-Ganz catheterization. Chest 1976;70:790–2. [8] Braverman AC, Coplen SE, Mudge GH, Lee RT. Ruptured chordae tendinae of the tricuspid valve as a complication of endomyocardial biopsy in heart transplantation. Am J Cardiol 1990;66:111–3. [9] Res JC, De Cock CC, Van Rossum AC, Schreuder J. Entrapment of tined leads. Pacing Clin Electrophysiol 1989;12:1583–5. [10] Rajs J. Postmortem finding and possible causes of unexpected death in patients treated with intraventricular pacing. Pacing Clin Electrophysiol 1983;6:751–60.
Fig. 1. (A) Transthoracic echocardiographic study showing a severe tricuspid regurgitation (apical four-chamber view). (B) Parasternal short axis view showing a ruptured tricuspid tendinae chordae (arrow). (C) Paraesternal short axis view, showing the ruptured tricuspid tendinae chordae higher depth (arrow). RV, right ventricle; RA, right atrium; LV, left ventricle; LA, left atrium; TV, tricuspid valve; PM, pacemaker lead.