Three-dimensional echocardiography location of permanent pacemaker or automatic implantable cardioverter-defibrillator leads to asses the mechanism of tricupid regurgitation

by Alena Ftáčniková1, MD and Luigi P. Badano2, MD, PhD
1National Institute of cardiovascular diseases of Bratislava, Bratislava, Slovak Republic
2Department of cardiac, thoracic and vascular sciences, University of Padua School of Medicine, Padua, Italy

Clinical Case

  • Previous acute coronary syndrome, he underwent percutaneous coronary intervention
  • VVI pace-maker implantation in 2015
  • ECG: Pace-maker rhythm with baseline atrial fibrillation (63 bpm)
  • NYHA II. 3/VI holosystolic, not irradiating, murmur heard on right parasternal position
  • Echocardiography requested for cardiac risk stratification before non-cardiac surgery

Two-dimensional echocardiography, apical 4-chamber view showing dilated left and right atrium. The pacemaker lead is visible (white arrow). Color Doppler shows significant tricuspid regurgitation

Spectral CW Doppler of tricuspid valve regurgitant flow from the apical 4-chamber view showing dense, holosystolic, signal with parabolic shape. Peak velocity is compatible with normal systolic pulmonary artery pressure.

Vena contracta diameter and PISA radius of tricuspid regurgitation jet were 8 mm and 9 mm, respectively

Soprahepathic vein PW sampling showed reversal systolic flow (arrow). Multiparametric assessment of severity of tricuspid regurgitation conclusive for moderate-severe degree.

Tricuspid annulus was mildly dilated (22 mm/m2) and there was no apparent abnormality of leaflets. The pace-maker wire is clearly visible but presence/absence of interference with anterior leaflet motion was difficult to assess by 2DE

Transthoracic three-dimensional full volume acquisition. En face view In His Mind and of the tricuspid valve from the right ventricular perspective.
The red arrow shows the interference of the pacemaker lead with the anterior leaflet of the tricuspid valve.

Abbreviations: ATL, anterior tricuspid leaflet; PTL, posteriori tricuspid leaflet; STL, septal tricuspid leaflet.

Transthoracic two- (left panel) and three- dimensional full volume (right panel) acquisition in a patient with mild tricuspid regurgitation after pace-maker implant. On the right panel, en face view of the tricuspid valve from the right ventricular perspective, check The red arrow shows the the pacemaker lead positioned in the commissure between the posterior and the septal leaflet of the tricuspid valve with no interference with valve leaflet motion

Key messages

2D/Doppler echocardiography enabled:

  • Identification and quantitation of tricuspid regurgitation
  • Estimation of pulmonary artery systolic pressure

3D echocardiography allowed:

  • Direct visualization of device-lead position and its relationship with tricuspid valve leaflets
  • Accurate identification of the mechanism of tricuspid regurgitation
  • Measurement of cardiac chamber size and function


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