Heart rate optimization to reduce tricuspid regurgitation in patients with atrial fibrillation and relative bradycardia: A case report

A 74-year-old male with end-stage renal disease was referred for treatment of syncope and hypotension episodes during dialysis. The patient had a history of sick sinus syndrome that was managed with a VVI pacemaker, maintaining a heart rate of approximately 60 bpm, due to atrial fibrillation. Transthoracic echocardiography revealed massive tricuspid regurgitation (TR), which was identified as a significant contributor to the patient's symptoms. Surgical intervention for TR was initially considered, however echocardiographic examination with pulse Doppler of the tricuspid inflow waveform indicated that ventricular filling efficiency could be improved by increasing the pacemaker's heart rate to 80 bpm. This adjustment was validated during right heart catheterization, confirming enhanced efficiency and leading to the decision to monitor the patient's condition with the new pacemaker setting instead of proceeding with surgery. Over the next 5 months, the patient's condition significantly improved, with TR severity decreasing to moderate. This case highlights the importance of tailored heart rate optimization in managing complex heart failure, demonstrating the effectiveness of noninvasive methods in improving outcomes for patients with significant tricuspid valve disease and relative bradycardia with atrial fibrillation. Learning objective: Assessing the optimal heart rate in patients with heart failure is crucial, requiring a case-by-case evaluation rather than relying on evidence from large clinical trials. In this case, characterized by relative bradycardia with chronic atrial fibrillation and severe tricuspid valve regurgitation, we determined the optimal heart rate using the Doppler waveform of the tricuspid valve inflow to assess whether an increase in heart rate could enhance cardiac output without reducing stroke volume.