An 82-year-old woman comes to the office due to fatigue, abdominal discomfort, and lower extremity swelling. She also occasionally feels an uncomfortable pulsation in her neck. Six weeks ago, the patient underwent pacemaker implantation due to sick sinus syndrome. Episodes of lightheadedness that she had experienced before the procedure have now resolved. The patient is afebrile, and other vital signs are normal. Physical examination reveals bilateral, lower extremity edema and a tender, pulsatile liver. The lungs are clear on auscultation. The pacemaker implantation site has healed normally. Complete blood count is normal. What is the most likely diagnosis?

Question

An 82-year-old woman comes to the office due to fatigue, abdominal discomfort, and lower extremity swelling.  She also occasionally feels an uncomfortable pulsation in her neck.  Six weeks ago, the patient underwent pacemaker implantation due to sick sinus syndrome.  Episodes of lightheadedness that she had experienced before the procedure have now resolved.  The patient is afebrile, and other vital signs are normal.  Physical examination reveals bilateral, lower extremity edema and a tender, pulsatile liver.  The lungs are clear on auscultation.  The pacemaker implantation site has healed normally.  Complete blood count is normal.  What is the most likely diagnosis?

Quizplus · Accepted Answer

11ec160b_3aa4_c20b_9249_55330575f439_MD0001_00 This patient likely has tricuspid valve regurgitation (TR) due to an adverse effect of her permanent pacemaker. The right ventricular lead of an implantable pacemaker or cardioverter-defibrillator passes through the superior vena cava into the right atrium and then through the tricuspid valve orifice to terminate on the endocardium of the right ventricle. Damage to the tricuspid valve leaflets or inadequate leaflet coaptation can sometimes occur, leading to severe TR in some patients. Severe TR typically presents with right-sided heart failure. Patients can have distended jugular veins, pulsatile and tender hepatomegaly, abdominal distension with ascites, and lower extremity edema. The lungs are clear on auscultation in the absence of concomitant left-sided heart disease. Cardiac examination typically reveals a holosystolic murmur best heard at the left lower sternal border; the murmur intensifies with maneuvers that increase right ventricular preload (eg, deep inspiration, leg raise). (Choice A) Causes of aortic valve regurgitation include rheumatic heart disease and aortic root dilation. Severe disease can lead to left-sided heart failure; however, pulmonary edema with crackles on lung auscultation would be expected. (Choice B) Constrictive pericarditis can result from chronic pericardial inflammation in the setting of infection or rheumatologic disease. It typically manifests with signs and symptoms of right-sided heart failure; however, the relationship between this patient's heart failure symptoms and recent pacemaker placement makes TR more likely. (Choice C) Infective endocarditis may affect the tricuspid valve and lead to TR; however, tricuspid involvement typically develops in patients with a history of injection drug use. In addition, this patient's lack of fever makes infective endocarditis unlikely. (Choice D) Severe pulmonic valve regurgitation can lead to right-sided heart failure. Causes of pulmonic valve regurgitation include rheumatic heart disease and endocarditis, but it is not associated with pacemaker placement as pacemaker leads do not cross the pulmonic valve. Educational objective: Severe tricuspid valve regurgitation (TR) can lead to right-sided heart failure, evidenced by jugular venous distension, hepatomegaly, lower extremity edema, and the absence of pulmonary edema. Permanent pacemaker placement can cause TR because the right ventricular lead passes through the tricuspid valve orifice and can disrupt valve closure.

An 82-Year-Old Woman Comes to the Office Due to Fatigue