Lancisi's Sign After Implantation of a Pacemaker.

A 57-year-old woman with a history of sick sinus syndrome who underwent implantation of a dual-chamber pacemaker with a lead positioned in the right ventricular apex and a lead positioned in the right atrial appendage 18 months prior presented with significant lower-limb edema, ascites, and a weight gain of 15 kg over a 6-week period. On cardiovascular examination, the patient was noted to be in sinus rhythm with frequent short episodes of atrial fibrillation and a grade 2/6 pansystolic murmur along the left sternal border that was louder with inspiration. A large palpable venous systolic pulsation was clearly evident on jugular venous examination. This venous systolic pulsation represents giant C-V waves, known as “Lancisi’s sign,” with a variability in the timing between sinus rhythm and atrial fibrillation (Fig. 1 and Video 1 ; view video online). Transesophageal echocardiography revealed a lack of coaptation between the posterior and septal leaflets of the tricuspid valve (Fig. 1) with an eccentric jet of tricuspid regurgitation as a result of the right ventricular pacemaker lead impinging on the posterior leaflet.

Figure 1

Large venous distension of the right internal jugular vein (left) as a result of severe tricuspid regurgitation caused by a right ventricular pacemaker lead restricting coaptation of the septal and posterior leaflets of the tricuspid valve as shown on 3-dimensional transesophageal echocardiography (right). LV, left ventricle; RV, right ventricle.

Lancisi’s sign is found in cases of severe tricuspid regurgitation in which the pulsation from right ventricular contraction is fused with the c wave, which normally occurs during closure of the tricuspid valve with loss of the x descent and followed by an augmented y descent. Tricuspid regurgitation after implantation of a pacemaker or defibrillator lead into the right ventricle may occur as a result of perforation of one of the valve leaflets, mechanical inhibition of valve coaptation, entrapment of a leaflet, or damage to papillary muscles or chordae tendinae. In this case, the diagnosis was lack of leaflet coaptation. After implantation of a lead across the tricuspid valve, this is an increasingly common finding, and significant tricuspid regurgitation may occur in 10% to 39% of patients.2, 3

The patient was treated with intravenous diuretics followed by extraction of the right ventricular lead. A new lead was positioned in a posterolateral branch of coronary sinus with left ventricular capture and a significant improvement in the degree of tricuspid regurgitation. The patient has remained clinically well since undergoing this procedure with a normal jugular venous pulse.

This case demonstrates an important clinical finding as a result of tricuspid regurgitation secondary to a pacemaker lead insertion. This is an increasingly recognized complication of implantable devices that may require further evaluation.

Disclosures

The authors have no conflicts of interest to disclose.