Pulsed Doppler echocardiography in the assessment of tricuspid regurgitation

Tricuspid Insufficiency Does Not Increase Early After Permanent Implantation of Pacemaker Leads

BACKGROUND

Interference between pacemaker (PM) lead and tricuspid apparatus may cause tricuspid regurgitation (TR). However, data regarding TR in patients with implanted PM are controversial. Our aim is to find out the degree of TR in a group of patients before and following PM implantation in a prospective manner.

METHODS

The study group consisted of the patients referred for implantation of permanent PM or implantable cardioverter defibrillator (ICD). All patients underwent two-dimensional and Doppler echocardiographic evaluation before and after device implantation. The severity of TR was qualitatively classified into four groups as normal or trivial, mild, moderate, or severe. All studies were reviewed for accuracy by a second independent interpreter.

RESULTS

Sixty-one patients (mean age 53 +/- 8 years, 44 male) referred for PM (n = 55) or ICD (n = 6) implantation consisted of the study population. Echocardiographic degree of TR was mild in 21 (70%), moderate in 7 (23%) and severe in 2 (7%) patients before PM implantation. Following device implantation, mild TR was noted in 23 (76%), moderate in 10 (33%), and severe in 2 (6%) cases. After the procedure, the TR severity was increased from normal/trivial to mild in 5 (16%) cases and from mild to moderate in 3 (10%). There was no worsening of the severity of TR in patients with moderate regurgitation following device implantation. The severity of TR did not change at a mean follow-up of 6 +/- 3 months.

CONCLUSIONS

New or worsening TR is relatively rare after PM implantation. It is not associated with an acute worsening or clinical deterioration. But echocardiographic follow-up is recommended to monitor other complications in chronic phase.

Pulsed Doppler echocardiographic detection of the origin of musical murmurs in a case of pacemaker implantation

We report a case of systolic and diastolic musical murmurs that developed 4 years after DDD pacemaker implantation. Echocardiographic examination disclosed no evidence of serious pacemaker-related complications. Pulsed Doppler examination with a sample volume at the right ventricular portion of a pacemaker lead showed prominent harmonic signals. The timing of the signals was consistent with that of musical murmurs. We considered vibration of the pacemaker lead as a possible origin of the musical murmurs. Systolic and diastolic musical murmurs can develop without serious cause in a patient with a transvenous pacemaker. Pulsed Doppler examination was useful in detecting the origin of musical murmurs.

Agitated colloid is superior to saline and equivalent to levovist in enhancing tricuspid regurgitation Doppler envelope and in the opacification of right heart chambers: a quantitative, qualitative, and cost-effectiveness study

BACKGROUND

Doppler spectrum of tricuspid regurgitation (TR) is used to noninvasively assess right ventricular (RV) pressure. With mild TR, the native (Nat) TR envelope may not allow accurate pressure evaluation. Proprietary contrast agents, such as Levovist (Lev) can be used to augment TR Doppler and opacify right-sided heart chambers, but they are expensive, and their efficacy has not been objectively evaluated in patients with difficult baseline studies or compared with less expensive saline (Sal) or colloid solutions, such as Gelofusine (Gel).

METHODS

Twenty-five consecutive patients with poor quality Nat TR envelopes on transthoracic echocardiogram were reexamined after serial intravenous injection of 3 contrast agents (Sal, Gel, and Lev). Doppler signals for each agent recorded on video and digitally on optical disk were assessed for signal quality, estimated RV pressure, interobserver and intraobserver variation, and longevity of signal. Quality of right ventricular-right atrial (RV-RA) opacification was also determined for Sal and Gel. Of the 25 patients, 9 underwent percutaneous right-sided heart catheterization. We used the pressures obtained from the catheterization to independently evaluate the pressure estimates from echocardiography.

RESULTS

All 3 contrast agents significantly improved the mean quality grade (grades 0-5) of TR envelopes (Nat 1.12, Sal 1.97, Gel 2.56, Lev 2.41, P <.001), decreased the number of uninterpretable envelopes (grade 0) (Nat 49%, Sal 12%, Gel 4%, Lev 12%, P <.0001 for comparison of each agent relative to Nat), and improved the correlation between echocardiographic and catheter-derived RV-RA pressure measurements (Nat r = 0.65, Sal r = 0.75, Gel r = 0.90, Lev r = 0.88). The persistence of enhanced Doppler signals of interpretable quality (> grade 1) was greater for Lev (15.8 seconds) and Gel (15 seconds) than Sal (7.6 seconds) (P =.002). Opacification of RV and RA, measured as mean luminosity score during 2-dimensional harmonic imaging, was significantly higher for Gel than Sal (92.84 +/- 31.2 vs 56.06 +/- 25.6, respectively; P =.0003). Sal, Gel and Lev, respectively, cost $0.10, $2.50, and $75.00 per study.

CONCLUSION

Agitated colloid is a novel, effective, and inexpensive alternative to proprietary agents and saline for the assessment of pulmonary systolic pressure and right-sided heart opacification.