Severe Tricuspid Regurgitation With Chordae Tendinae Rupture After Leadless Pacemaker Implantation

A 74-year-old woman with a past medical history of mitral valve replacement and inferior wall myocardial infarction was admitted to hospital due to edema and malaise 2 months after leadless pacemaker (LP; MicraTM, Medtronic) implantation for bradycardic atrial fibrillation. Preoperative transthoracic echocardiography (TTE) had shown moderate tricuspid regurgitation (TR) without tricuspid valve prolapse (Figure A). A total of 11 deployments of LP were required due to the difficulty in finding a suitable site with appropriate thresholds. On TTE at the current admission, the tricuspid valve showed severe TR with a flail septal leaflet, suggesting chordae tendinae rupture (Figure B,C). The liver was still congested despite the use of high-dose diuretics, and tricuspid valvuloplasty was conducted. Intraoperative findings included 2 chordal tears in the septal leaflet (Figure D, Supplementary Movie).

Figure.

(A) No flail leaflets of tricuspid valve. (B) Flail tricuspid septal leaflet and severe TR flow. (C) Flail septal leaflet with chordae tendinae rupture. (D) Discovered during operation, 2 broken chordae of the septal leaflet. ATL, anterior tricuspid leaflet; PTL, posterior tricuspid leaflet; RA, right atrium; RV, right ventricle; STL, septal tricuspid leaflet; TR, tricuspid regurgitation; TTE, transthoracic echocardiography.

An ex vivo experiment using human hearts showed that tricuspid valve chordae tendinae rupture induced by LP is unlikely,¹ but in the present case we believe that LP did cause chordae tendinae rupture, possibly as a result of the repeated deployment. The history of myocardial infarction may have contributed to poor thresholds and vulnerability of cardiac tissue. With the increase in the number of elderly patients with comorbidities, LP implantation is expected to be chosen more frequently. There have been reports of other complications from frequent deployment,² so operators should carefully select an appropriate implantation site in cases of comorbid cardiac conditions.

Disclosures

K.Y. is a member of Circulation Journal’s Editorial Team.

COI Diclorsure

The authors declare no conflicts of interest.

Supplementary Files

Supplementary Movie. Surgical findings of tricuspid valvuloplasty.

Please find supplementary file(s);

http://dx.doi.org/10.1253/circj.CJ-21-0860

References

• 1.   Mattson AR, Zhingre Sanchez JD, Iaizzo PA. The fixation tines of the Micra^TM leadless pacemaker are atraumatic to the tricuspid valve. Pacing Clin Electrophysiol 2018; 41: 1606–1610.
• 2.   Fukaya H, Kishihara J, Ishizue N, Kameda R, Shimohama T, Arakawa Y, et al. Coronary artery injury caused by leadless pacemaker implantation. Circ J 2020; 84: 530.