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Misplaced pacemaker wire as a cause of mitral regurgitation
  1. J M Brophy
  1. james.brophy{at}

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In 1990, a 73 year old woman received a VVI pacemaker for second degree heart block. The patient first returned to the pacemaker clinic in 1996 for a routine evaluation. A loud systolic murmur (III/IV) was noticed at the lower left parasternal border. The clinical diagnosis was presumed to be tricuspid regurgitation caused by the cardiac pacemaker. The patient declined further investigation. She remained asymptomatic but finally consented in September 2001 to an echocardiogram. The four chamber view is shown below (left). This shows the pacemaker wire crossing the foramen ovale and lodging into the mitral valve apparatus. This has produced a pronounced inflammatory/sclerotic response at the level of the mitral valve which was associated with severe mitral regurgitation (estimated effective regurgitant orifice 0.6 cm2). The regurgitant jet was directed along the pacemaker wire medially. There was also moderate tricuspid regurgitation with a pulmonary artery pressure of 90 mm Hg.

In retrospect, the diagnosis of a misplaced pacemaker wire could have been suspected earlier as the paced ECG has a right bundle branch pattern (below right). So far, the patient has refused further investigations and treatment of these conditions.

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