Echocardiographic assessment of tricuspid regurgitation during ventricular demand pacing

Twenty patients from our pacemaker clinic population were assessed clinically and by saline contrast echocardiography (subxiphoid view) to determine the prevalence of tricuspid regurgitation (TR) and, if TR was present, its mechanism. The patients had no known TR before lead placement, a single transvenous right ventricular pacing lead present more than 6 months (mean 52, range 7 to 138), ventricular demand pacing alternating with sinus rhythm and rate programmability. Each patient was studied in sinus rhythm and during ventricular pacing. Using the criterion of inferior vena cava (IVC) contrast reflux during ventricular systole to diagnose TR, no patient had evidence of TR in sinus rhythm, consistent with clinical examination. During ventricular demand pacing, jugular venous pulse cannon A waves developed in 10 patients, and 18 patients (including these 10) had IVC contrast reflux during ventricular systole. Analysis of the timing of IVC reflux revealed its close temporal relation to the timing of atrial systole rather than a fixed timing during ventricular systole. This reflux occurred with loss of normal atrioventricular (AV) synchrony and the underlying mechanism in all cases was shown to be right atrial contraction against a closed tricuspid valve. Two patients who did not have such a pattern with pacing maintained normal AV synchrony. These observations indicate that: TR is an uncommon accompaniment of ventricular demand pacing; the jugular venous pulse and IVC echocardiographic contrast patterns during ventricular demand pacing simulate TR when AV asynchrony [corrected] occurs; and the IVC contrast pattern of pacing induced AV asynchrony [corrected] is best termed the cannon A wave synchronous pattern.