The added value of three-dimensional echocardiography in the late diagnosis of a pacemaker complication in a patient with severe congestive heart failure: a case report

BACKGROUND: Three-dimensional echocardiography (3DE) presents an increasingly important role in the management of interventional cardiac procedures, overcoming limitations of conventional two-dimensional echocardiography (2DE). Early use of 3DE might have an added value in the diagnosis of device-related complications, such as lead induced tricuspid regurgitation (LITR), by providing better understanding of its mechanisms and ensuring a prompt and individually tailored treatment strategy. CASE SUMMARY: We report the case of a female patient with repeated hospitalizations for congestive heart failure in the past 2 years, who had a permanent single-chamber ventricular pacemaker (PM) implanted 10 years ago and a misleading diagnosis of severe tricuspid regurgitation (TR) secondary to annular dilation, based on 2DE. Conversely, current 3DE assessment of the TR mechanisms revealed that the PM lead was not placed between the commissures, but in the middle segment of the septal leaflet, causing impingement of the leaflet and severe TR. DISCUSSION: Given the growing indication for cardiac devices, it is necessary to better define LITR and to establish its impact on patient prognosis. Due to lacking in proper diagnostic techniques, LITR is generally recognized as a late complication of PM/ICD implantation. Two-dimensional echocardiography has important limitations, whereas 3DE provides more accurate information on the TV apparatus in relation to the endocardial leads. Our case shows the usefulness of 3DE for a correct diagnosis of a device-related complication. Its utility in the follow-up of patients receiving cardiac devices remains to be determined, as well as its potential value in the guidance of lead insertion.