A 70-year-old male patient was admitted to the department of cardiac surgery for surgical
repair of severe tricuspid regurgitation. He had a history of decompensated right
heart failure with recurrent hospitalizations. Four years earlier he had received
a VVIR pacemaker with a passive lead (Refino 58 ER, Oscor; Palm Harbor, FL, USA) due
to atrial fibrillation with atrioventricular conduction block. Three years later,
another passively fixed ventricular lead had been placed due to a failure of the original
pacemaker lead resulting in increasing impedance.
The chest X-ray at admission revealed a significantly enlarged heart and pleural effusions
due to right heart failure (Figure 1). The pacemaker leads did not show a parallel course through the tricuspid valve.
Transthoracic echocardiography confirmed severe tricuspid regurgitation with a moderate
impairment of right ventricular function (Additional file 1: Video S1). The left ventricle and the other heart valves did not show any pathologic
findings. However, one pacemaker lead was described as ‘whipping’ in the transthoracic
echocardiography (Additional file 1: Video S1).
Figure 1. Preoperative chest X-ray. Blue arrow: pleural effusion; Red arrow: different course of the two leads through
the tricuspid valve.
Clinical decision-making was guided by a multidisciplinary approach. Options considered
were a conservative approach due to the increased risk of postoperative right heart
failure, lead removal by percutaneous lead extraction or open surgical lead removal
including valve repair or replacement. Eventually the decision was taken for an open
surgical approach due to the patient’s good general health condition and the severely
dilated tricuspid annulus.
On-pump beating heart surgery was performed. One lead was perforating the posterior
papillary muscle, severely impairing valve movement (Additional file 1: Video S1, Figure 2). Although the lead was not perforating the leaflet itself, it prevented the free
margin of the posterior leaflet to close in systole due to its strong adhesion to
the papillary muscle and the ventricular wall. The leaflet itself was not altered.
The tip could not be completely removed, and can still be seen on the postoperative
chest X-ray (Figure 3). The second lead could be removed without problems. The valve was reconstructed
with a Contour 3D tricuspid annuloplasty ring (Medtronic Inc., Minneapolis, MN, USA).
However, the reconstructed valve showed again moderate regurgitation after weaning
from the heart-lung machine and was replaced with a stented bioprosthesis (Mosaic
Ultra Mitral, Medtronic Inc., Minneapolis, MN, USA). Epicardial leads were placed
on the right and left ventricle. The lead to the right ventricle was connected to
the pulse generator. The lead to the left ventricle was routed to the pacemaker pocket
to allow cardiac resynchronization therapy in the case of postoperative heart failure.
However, the patient could be weaned from cardiopulmonary bypass without need for
mechanical support or resynchronization. Postoperative valve function was good and
inotropic support could be stopped after four days. The left ventricular lead has
not been connected due to sufficient left ventricular function and the absence of
heart-failure symptoms. The patient was discharged home 12Â days after surgery in good
condition and was stable thereafter.
Figure 2. Intraoperative view of the perforating lead. Blue arrow: pacemaker lead perforating the papillary muscle.
Figure 3. Postoperative chest X-ray. Blue arrow: residual lead fragment.