[HSF] Traumatic tricuspid regurg

[ebender001 at charter.net]

This case begs several questions.  What was the pacer put in for initially?  Is the patient pacer dependent?  Was there pus in the pocket or was this just a pocket erosion?  What was the interval between pacer insertion and pocket infection?  Why no organisms cultured?  Why do you think that this is endocarditis?  Do you think the leads really needed to be pulled?

If the patient is not pacer dependent, has no symptoms, and has no signs of infection, I would do nothing.  On the other extreme, if the patient has to have a pacemaker, then tricuspid repair should be a fairly easy option ranging from "bicuspidization" to leaflet repair and neo-chords, depending on the anatomy.  If it is infection alone that you are treating, then treat it like right sided endocarditis, ie, antibiotics in the absence of heart failure.

These are the cases I have found are extremely easy to do via "heartport" approach, unfortunately we rarely get them referred.

Ed Bender, MD


---- nand kejriwal <nkkejriwal at gmail.com> wrote: 
> Dear members
> 
>  An interesting case has been referred to me. The patient is a 65 year old
> lady who underwent dual chamber pacing a few years ago. Recently she
> presented to the cardiologist with pacemaker pocket site infection. The
> cultures did not grow any bug, but the generateor was eroding through the
> skin. Last week the cardiologist pulled out all the hardwares. Apparently he
> tore one of the pap m of the TV while removing the RV lead. Now the patient
> has severe TR. I am enclosing the echo frames showing the bit of pap m with
> attached chordae flopping in & out of RV resulting in severe TR. The patient
> had mild to mod TR before the lead removal. There is no evidence of TV
> endocarditis on echo. The annulus measures 40mm. Normal coronaries.
> 
> What is the best option?
> Repair by suturing the muscle back and putting an annuloplasty ring? Will it
> work? My concern is that if the lead were infected, would it be wise to
> leave the leaflets behind?
> 
> Or, remove all the leaflets with chordae and insert a bioprosthesis?
> 
> I am also planning to attach RV & LV epicardial leads. I shall sew the LV
> lead close to the 1st OM artery posteriorly. What is the best spot for the
> RV lead?
> 
> Thanks
> 
> Nand