A 72-year-old woman comes to the emergency department with fatigue and bilateral leg swelling. Her pulse is 92/min, and respirations are 24/min. Six weeks ago, the patient underwent pacemaker implantation due to sick sinus syndrome. Physical examination shows jugular venous distention and pitting edema of the lower extremities. Her abdomen is distended with shifting dullness and tender hepatomegaly is present. Cardiovascular examination shows a holosystolic murmur heard best at the left lower sternal border that increases in intensity with inspiration. The pacemaker implantation site has healed normally. Complete blood count is normal. What is the most likely diagnosis?

Question

A 72-year-old woman comes to the emergency department with fatigue and bilateral leg swelling. Her pulse is 92/min, and respirations are 24/min. Six weeks ago, the patient underwent pacemaker implantation due to sick sinus syndrome. Physical examination shows jugular venous distention and pitting edema of the lower extremities. Her abdomen is distended with shifting dullness and tender hepatomegaly is present. Cardiovascular examination shows a holosystolic murmur heard best at the left lower sternal border that increases in intensity with inspiration. The pacemaker implantation site has healed normally.  Complete blood count is normal.  What is the most likely diagnosis?

Quizplus · Accepted Answer

Eductional 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.

A 72-Year-Old Woman Comes to the Emergency Department with Fatigue