title: Case report: Pacemaker lead perforation of a papillary muscle inducing severe tricuspid regurgitation.
abstract: BACKGROUND
  We report a rare but severe pacemaker complication of a pacemaker lead perforating the papillary muscle. This induced severe tricuspid regurgitation and right heart failure. Patients suffering from right heart failure have an increased operative risk of open-heart surgery and therefore represent a clinical challenge due to the lack of clear guidelines.
  
  
  METHODS
  A 70-year-old male patient presented with severe tricuspid regurgitation and a history of decompensated right heart failure. One pacemaker lead was described as 'whipping'. Four years earlier he had received a VVIR pacemaker with a passive lead. This lead failed after three years and a new ventricular lead had been placed. We performed on-pump beating heart surgery after a multidisciplinary decision process. One lead was perforating the posterior papillary muscle, severely impairing valve movement. The tricuspid valve was replaced with a stented bioprosthesis. Epicardial pacemaker wires were placed on the right and left ventricle to enable cardiac resynchronization therapy in the case of postoperative heart failure. However, the patient recovered quickly without left ventricular pacing and could be discharged home 12 days after surgery.
  
  
  CONCLUSIONS
  This particular case emphasizes the importance of meticulous surgical technique during pacemaker lead implantation and a tight postoperative follow-up including echocardiography in complicated cases. The management of patients with an indication for lead removal having developed secondary severe tricuspid valve dysfunction inducing ventricular impairment represents a clinical challenge and should be approached by a multidisciplinary team.
authors.affiliation: Department of Cardiac Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Level 20A, 1090, Vienna, Austria. martin.andreas@meduniwien.ac.at.
authors.forename: Martin
authors.initials: M
authors.lastname: Andreas
authors.affiliation: Department of Cardiac Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Level 20A, 1090, Vienna, Austria. franz.gremmel@meduniwien.ac.at.
authors.forename: Franz
authors.initials: F
authors.lastname: Gremmel
authors.affiliation: Department of Cardiac Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Level 20A, 1090, Vienna, Austria. andreas.habertheuer@meduniwien.ac.at.
authors.forename: Andreas
authors.initials: A
authors.lastname: Habertheuer
authors.affiliation: Department of Cardiac Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Level 20A, 1090, Vienna, Austria. claus.rath@meduniwien.ac.at.
authors.forename: Claus
authors.initials: C
authors.lastname: Rath
authors.affiliation: Department of Cardiac Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Level 20A, 1090, Vienna, Austria. claudia.oeser@meduniwien.ac.at.
authors.forename: Claudia
authors.initials: C
authors.lastname: Oeser
authors.affiliation: Department of Cardiac Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Level 20A, 1090, Vienna, Austria. cesar.khazen@meduniwien.ac.at.
authors.forename: Cesar
authors.initials: C
authors.lastname: Khazen
authors.affiliation: Department of Cardiac Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Level 20A, 1090, Vienna, Austria. alfred.kocher@meduniwien.ac.at.
authors.forename: Alfred
authors.initials: A
authors.lastname: Kocher
mesh_terms: D000368:Aged; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D008297:Male; D010138:Pacemaker, Artificial / Q000009:adverse effects*; D010210:Papillary Muscles / Q000293:injuries* / Q000601:surgery; D014262:Tricuspid Valve Insufficiency / Q000175:diagnosis / Q000209:etiology* / Q000601:surgery