Abstract 19093: Paradoxical Improvement of Tricuspid Valve Incompetence Severity Following Implantation of Ventricular Leads

Abstract

Background: Cardiac rhythm management devices (CRMD) require an endocardial ventricular lead to be placed across the tricuspid valve. Worsening tricuspid regurgitation (TR) with implantation of CRMD has been described. We report the incidence of improvement in TR after CRMD placement, which is an unexpected finding. Methods: We retrospectively reviewed 148 patients (age 68±15) that received a CRMD. TR, ejection fraction (EF) and pulmonary artery systolic pressure (PASP) measured by Doppler echocardiography before and after CRMD implantation were analyzed. The TR was graded according to the degree of severity as mild, moderate and severe. A scale of 0-4 according to the grade of severity was used. Improvement in the severity of TR was classified corresponding with the reduction in grades of severity of TR as follows: minimal (<1grade), slight (1), and significant reduction (≥2). Results: Mean follow-up time was 30±12 months. Thirty-nine (26%) patients experienced improvement in the severity of TR (from 1.7±0.8 to 0.9±0.7; p=0.0001-5) after placement of a CRMD. The remaining 109 patients had an increase in the severity of TR (from 0.1±0.5 to 1.4±0.9; p=0.0005-10). Reduction in TR was associated with improvement in EF (from 41±19 to 47±14%; p=0.01) and PASP (from 45±15 to 36±14mmHg; p=0.002-2). Patients that had increase in TR did not have a significant change in their EF (from 40±17 to 42±15%; p=0.07) and had worsening of their PASP (from 38±14 to 42±16mmHg; p=0.002). Evaluation of improvement in TR per type of device implanted revealed no difference between patients who received pacemakers (PPM), defibrillators (ICD) or cardiac resynchronization therapy devices (CRT) (ICD/CRT vs PPM p=0.12; ICD vs PPM p=0.22; ICD vs CRT p=0.29 and CRT vs PPM p=0.07). Conclusion: Severity of TR may improve in some patients after CRMD placement. This could be attributed to diuresis and optimization of medical therapy at the time of CRM implant or restoration of AV synchrony with pacing, as evidenced by the reduction in PASP and improved EF among those patients.