A 72-year-old man comes to the office due to fatigue and lower extremity swelling for the last several weeks. He also has a feeling of pulsation in his neck when he lies down. He has no chest pain. The patient takes lisinopril and amlodipine for hypertension. He underwent permanent pacemaker implantation for sick sinus syndrome 6 months ago. He is a lifetime nonsmoker. The patient has no family history of cardiovascular disease. Blood pressure is 112/70 mm Hg and pulse is 79/min and regular. The jugular veins are distended with the patient in the sitting position. A 3/6 holosystolic murmur is heard over the left lower sternal border. The lungs are clear on auscultation. The liver is enlarged and mildly tender on palpation. Bilateral 3+ edema is present in the lower extremities. Which of the following is the most likely diagnosis?

Question

A 72-year-old man comes to the office due to fatigue and lower extremity swelling for the last several weeks.  He also has a feeling of pulsation in his neck when he lies down.  He has no chest pain.  The patient takes lisinopril and amlodipine for hypertension.  He underwent permanent pacemaker implantation for sick sinus syndrome 6 months ago.  He is a lifetime nonsmoker.  The patient has no family history of cardiovascular disease.  Blood pressure is 112/70 mm Hg and pulse is 79/min and regular.  The jugular veins are distended with the patient in the sitting position.  A 3/6 holosystolic murmur is heard over the left lower sternal border.  The lungs are clear on auscultation.  The liver is enlarged and mildly tender on palpation.  Bilateral 3+ edema is present in the lower extremities.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d860_7618_bc81_61f4043e69f2_MD0003_00 This patient likely has severe tricuspid regurgitation (TR) due to an adverse effect of his permanent pacemaker. The right ventricular lead of a transvenous implantable pacemaker or cardioverter-defibrillator passes through the superior vena cava into the right atrium and then through the tricuspid valve to terminate in the endocardium of the right ventricle. Damage to the tricuspid valve leaflets or inadequate leaflet coaptation can occur, leading to severe TR in 10%-20% of patients. Chronic, 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. Cardiac examination typically reveals right ventricular heave and a holosystolic murmur best heard at the left sternal border; the murmur intensifies with maneuvers that increase right ventricular preload (eg, deep inspiration, leg raise). The diagnosis of TR is confirmed by echocardiogram. (Choice A) Mitral chordal rupture is not associated with pacemaker placement as the leads do not cross the mitral valve (even in a biventricular pacemaker). Spontaneous rupture can occur due to myxomatous degeneration in patients with mitral valve prolapse; the typical presentation is with prominent pulmonary edema and a holosystolic murmur heard at the cardiac apex. (Choice B) Pulmonic valve stenosis most commonly occurs as a congenital defect and is often asymptomatic; however, some patients develop right-sided heart failure. Physical examination typically reveals a systolic ejection murmur best heard at the left upper sternal border; as with TR, the murmur intensifies with increases in right ventricular preload. (Choice C) A thoracic aortic aneurysm usually remains asymptomatic. It rarely presents with progressive aortic regurgitation as evidenced by a diastolic murmur and signs of left-sided heart failure (eg, pulmonary edema). (Choice E) A ventricular septal defect typically causes a palpable thrill and a harsh holosystolic murmur with maximal intensity at the left midsternal border. This defect is not typically associated with permanent pacemakers. Educational objective: Transvenous lead placement through the tricuspid valve can cause severe tricuspid regurgitation due to direct valve leaflet damage or inadequate leaflet coaptation. This complication should be suspected in patients presenting with right-sided heart failure following implantable pacemaker or cardioverter-defibrillator placement. References: Severe symptomatic tricuspid valve regurgitation due to permanent pacemaker or implantable cardioverter-defibrillator leads. (http://www.ncbi.nlm.nih.gov/pubmed/15893186)

A 72-Year-Old Man Comes to the Office Due to Fatigue