PMC8213207_01
Case 1: Septal leaflet impingement by pacemaker lead. Central lead position with impingement of the septal leaflet is shown via subcostal en face view of the tricuspid valve (A) and via the commissural view in the parasternal short axis (B; left side) and the corresponding 90  view of the septal and the anterior leaflet (B; right side). AL, anterior leaflet; PL, posterior leaflet; SL, septal leaflet; RA, right atrium; RV, right ventricle; PSC, postero-septal commissure; ASC, antero-septal commissure; MV, mitral valve; PV, pulmonary valve; AV, aortic valve.
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F2
The exact lead position can be determined by TTE (Figure 2), both in an en face view (Figure 2A) and in a biplane angulation with a TV commissural view in the parasternal short axis (Figure 2B, left side) and the corresponding 90  view of the septal and the anterior leaflet (Figure 2B, right side). This patient presented with right heart decompensation due to severe structural tricuspid regurgitation (TR).
PMC8213207_02
Case 2: Leaflet perforation. Transthoracic en face view of the tricuspid valve shows the pacemaker lead passing through the posterior leaflet (A). In transesophageal echocardiography, a deep-transesophageal commissural view of the tricuspid valve (B, left side) with the corresponding 90  view of the septal and the posterior leaflet (B, right side) proves perforation of the posterior leaflet. AL, anterior leaflet; PL, posterior leaflet; SL, septal leaflet; PSC, postero-septal commissure; ASC, antero-septal commissure.
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F3
TOE (Figure 3). The patient did not have severe TR and did not report clinical signs of heart failure.
PMC8213207_03
Case 3: Anterior leaflet impingement by a pacemaker lead. Two trans-tricuspid pacemaker leads are present (A). The transthoracic subcostal en face view of the tricuspid valve shows one lead in the antero-posterior commissure and the other in the antero-septal commissure (B). Leaflet impingement of the anterior leaflet causes "torrential" tricuspid regurgitation (C). AL, anterior leaflet; PL, posterior leaflet; SL, septal leaflet; RA, right atrium; RV, right ventricle; LA, left atrium; TV, tricuspid valve; MV, mitral valve.
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F4
The second pacemaker lead is located in the antero-septal commissure (Figure 4). The patient presented with peripheral edema.