TARIQUE HUSSAIN, M.B.B.CH., WILLIAM BRODIE KNIGHT, M.B.B.S., and KAREN A. MCLEOD, M.D.
From the Department of Cardiology, Royal Hospital for Sick Children, Glasgow, United Kingdom
We describe a case of tricuspid stenosis in a young woman 11 years after endocardial ventricular lead implantation. The cause of thestenosis appears to have been perforation of the septal leaﬂet by the lead at the time of insertion. We further describe successful management with percutaneous balloon valvuloplasty without the need for lead removal. (PACE 2009; 32:140–142) pacemaker, artiﬁcial, tricuspid valve stenosis, heart defects, congenital, complications, balloon dilatation Introduction Tricuspid stenosis is a recognized butuncommon complication of transvenous ventricular pacing.1–9 We present the case of a 17-year-old female with surgically repaired congenital heart disease who developed tricuspid stenosis 11 years after implantation of an endocardial VVI pacemaker. We describe successful management by percutaneous balloon valvuloplasty. Case History An 11-week-old infant weighing 3.5 kg underwent surgical repair ofdouble outlet right ventricle and large ventricular septal defect (VSD) with Dacron patch complicated by complete heart block. Two weeks after surgery she had implantation of an epicardial dual chamber pacemaker. Moderate heart failure persisted and at 5 months of age she underwent surgical closure of a moderatesized muscular VSD. Thereafter it was noted that she was in sinus rhythm for most ofthe time. At 6 years of age, the threshold on the epicardial ventricular lead rose sharply. As she was still predominantly in sinus rhythm and weighed 18 kg, it was elected to change her pacing system to an endocardial back-up VVI pacemaker. A bipolar transvenous tined lead was positioned in the right ventricle via the left subclavian vein. The operators commented on difﬁculty in positioning thelead which they ascribed to VSD patch. The previous pacemaker generator was removed and the epicardial leads were capped. At 17 years of age, she was asymptomatic but was noted to have a new mid-diastolic murFinancial Support: None. Address for reprints: Tarique Hussain, M.D., Department of Cardiology, Royal Hospital for Sick Children, Dalnair Street, Glasgow, UK. Fax: 01412019204; e-mail:email@example.com. Received January 20, 2008; revised March 1, 2008; accepted March 11, 2008. 2009, The Authors. Journal compilation
mur at the lower left sternal edge. Her pacemaker function was satisfactory with stable lead impedance and threshold and satisfactory battery parameters but transthoracic echocardiography (TTE) demonstrated tricuspid stenosis with mild tricuspid regurgitation. Shetherefore underwent trans-esophageal echocardiography (TEE) and cardiac catheterization. TEE showed the lead passing through the septal leaﬂet of the tricuspid valve (TV) (Fig. 1), thereby impairing its opening. The mean TV gradient on TEE was 8 mmHg and end-diastolic gradient at cardiac catheterization 8 mmHg. In view of the moderate tricuspid stenosis, balloon angioplasty was undertaken (Fig. 2).The maximum diameter of the tricuspid valve annulus on TEE was 34 mm. The valve was dilated with a 25 mm (diameter) × 40 mm (length) Cristal balloon inﬂated to 4 atmospheres. There was complete loss of waist on balloon inﬂation. Thereafter the catheter-derived TV end-diastolic gradient fell to 4 mmHg with only mild tricuspid regurgitation (as before). This corresponded with a mean gradient on TEE of4 mmHg. The procedure was uncomplicated and 6 months later she remained asymptomatic, no longer had any diastolic murmur, and the mean TV gradient on TTE was still only 4 mmHg. Discussion Tricuspid stenosis is a rare complication of transvenous pacing with only six case reports in the literature.2,4,5,7,8 In addition there are four case reports of tricuspid stenosis following endocarditis on an...