Bibliographic record
Abstract
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. 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.1Chang J.D. Manning W.J. Ebrille E. Zimetbaum P.J. Tricuspid valve dysfunction following pacemaker or cardioverter-defibrillator implantation.J Am Coll Cardiol. 2017; 69: 2331-2341Crossref PubMed Scopus (116) Google Scholar 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.2Lee R.C. Friedman S.E. Kono A.T. Greenberg M.L. Palac R.T. Tricuspid regurgitation following implantation of endocardial leads: incidence and predictors.Pacing Clin Electrophysiol. 2015; 38: 1267-1274Crossref PubMed Scopus (33) Google Scholar, 3Al-Bawardy R. Krishnaswamy A. Bhargava M. et al.Tricuspid regurgitation in patients with pacemakers and implantable cardiac defibrillators: a comprehensive review.Clin Cardiol. 2013; 36: 249-254Crossref PubMed Scopus (73) Google Scholar 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. The authors have no conflicts of interest to disclose. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIxNWVhMGNmMzEwOWY2ZjI1OTMyMmU3MTJhZmNkN2Q2MSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc3NzQ2NTY2fQ.g28b71WDiHij1bLkPl40_Of3_c5lxod38uQIaJNmr4u323gPk0Lu_em0UsUaiD3UDIREyQZms6nnV4Qs-Ayg3rtvTi1tCWVTawX4PfTXdLB_gcDeHcz-ZvHiczbEexhxEh7epv1Ls01ZUTzKTC5kA3ox_v2AS_1fqIziTkm6J5-ELc_Sd5cz3ehbJ-TzhF_yJypmB8idUaJs3GSHY6I8Q3Njt9TBbzMWPIzlugk2OYtuIYoQLbB6ZNgdCfwWY2tkE_57_kjgOt9XQNOFYiBNl92-NsIi26Y7KBEprxs6HdJ1LwlGb0QNmoMqMji_ePoayeecES_r8NpUHIfMH8CJQA Download .mp4 (4.47 MB) Help with .mp4 files Video 1A large palpable venous systolic pulsation evident on jugular venous examination, which represents giant C-V waves, known as “Lancisi’s sign,” with a variability in the timing between sinus rhythm (initial 3 beats) and atrial fibrillation.
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.000 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.000 | 0.000 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.001 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".