We describe a case of tricuspid stenosis in a young woman 11 years after endocardial ventricular lead implantation. The cause of the stenosis 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 but uncommon 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 of double 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 moderatesizedmuscular VSD. Thereafter it was noted that she was in sinus rhythm for most of the 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 the lead 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: tarique@doctors.org.uk. 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. She therefore 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 8mmHg 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 of 4 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 endocardial pacing system.1,3,6,9 In the six previously reported cases without endocarditis, the etiology of the tricuspid stenosis was believed to be fibrosis secondary to tricuspid leaflet perforation in two patients4 and fibrosis as a result of the adherence of redundant loops of the lead to valvar and subvalvar tissue in four patients.2,5,7,8 We believe that the etiology of tricuspid stenosis in our patient was inflammation and fibrosis of the TV septal leaflet secondary to leaflet perforation by the lead. The reported management


ENDOCARDIAL LEAD CAUSING TRICUSPID STENOSIS

Figure 1. Showing TEE mid-esophageal right ventricular inflow–outflow view of heart at enddiastole. The right ventricular lead is seen perforating the septal leaflet of the tricuspid valve.

Figure 2. Thirty degree RAO projection showing a waist on balloon inflation in the region of the tricuspid valve. The waist disappeared by the end of the inflation. Also seen is the endocardial ventricular lead passing through the tricuspid valve orifice. The old capped epicardial leads are also seen.


of these cases has included medical management in three (offer of surgery declined in two),2,7,8 surgical lead removal and TV replacement in two,4,5 and surgical lead removal followed by tricuspid valvuloplasty in one.4 We present the only case of successful balloon valvuloplasty for this complication without need for lead removal. It was felt that if lead removal were required this would References
1. Enia F, Lo MR, Meschisi F, Sabella FP. Right-sided infective endocarditis with acquired tricuspid valve stenosis associated with transvenous pacemaker: A case report. Pacing Clin Electrophysiol 1991; 14:1093–1097. 2. Garrote C, Fidalgo ML, Iglesias-Garriz I, Corral F, Silvestre J, GarciaCalabozo R. [Tricuspid stenosis after pacemaker implantation without evidence of bacterial endocarditis. A case report]. Rev Esp Cardiol 2002; 55:988–990. 3. Hagers Y,Koole M, Schoors D, Van CG. Tricuspid stenosis. A rare complication of pacemaker-related endocarditis. J Am Soc Echocardiogr 2000; 13:66–68. 4. Heaven DJ, Henein MY, Sutton R. Pacemaker lead related tricuspid stenosis. A report of two cases. Heart 2000; 83:351– 352. 5. Lee ME, Chaux A. Unusual complications of endocar-
best be achieved by surgery but in view of the lasting reduction in gradient by balloon valvuloplasty, no further intervention has been necessary. We conclude that tricuspid stenosis secondary to perforation of a TV leaflet by a transvenous lead may be safely and successfully treated by percutaneous balloon valvuloplasty if lead function is otherwise normal.
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