Lead-induced Tricuspid Regurgitation Research Articles

Comparison of Outcomes in Patients With Heart Failure With Versus Without Lead-Induced Tricuspid Regurgitation After Cardiac Implantable Electronic Devices Implantations

Cardiac implantable electronic devices (CIED) implantations may cause lead-induced tricuspid regurgitation (LITR). Although patients with CIED have the risk of functional non-lead induced TR (Non-LITR). This study aimed to compare of clinical outcome between LITR and Non-LITR. The mechanism of TR was determined by 3-dimensional echocardiography. The primary end point was heart failure (HF) hospitalizations after CIED implantation. In patients with HF events, subsequent clinical outcomes after HF hospitalization were compared between no TR, LITR, and Non-LITR groups. In eligible 373 patients, 67 patients had HF hospitalization, of whom worsened TR was observed in 49 patients. In the remaining 307 patients, worsened TR was observed in only 10 patients (3.3%). Of the 49 patients with worsened TR, 18 patients (37%) had LITR. In 67 patients with HF hospitalization, 25 patients (37%) met rehospitalization. All severe LITR persisted after HF events. Meanwhile, severe Non-LITR improved to moderate or mild level. Cox proportional hazard model analyses revealed LITR was the independent risk factor of rehospitalization. Both LITR and Non-LITR were common at HF events after CIED implantations. However, LITR persisted and might contribute to a worse prognosis. In patients with TR after CIED implantations, 3-dimensional echocardiography should be performed to diagnose the LITR accurately, which may contribute to improving the clinical outcome.

Micra Pacemaker: Underutilized in High Risk Patients?

Background Micra transcatheter pacing systems were first brought onto the market in 2016. Currently the Micra pacemaker is indicated for VVIR mode in patients that experience symptomatic high-grade AV block, tachy-brady syndrome and individuals considered high risk for right atrial lead dislodgement. Our institution has utilized Micra pacing successfully in various clinical applications: limited transvenous access due to superior vena cava syndrome, right ventricular pacemaker lead induced tricuspid regurgitation, pacemaker infection and as described below, atrial fibrillation ablation shortly after pacemaker insertion. Case We report a case of a 72-year-old male with a history of symptomatic paroxysmal atrial fibrillation, mechanical aortic valve and morbid obesity who presented to our outpatient clinic for evaluation of his symptomatic atrial fibrillation. Despite increased Sotalol dosing, the patient continued to have symptomatic paroxysmal atrial fibrillation with symptoms of dizziness and near syncope. Outpatient monitoring revealed greater than 5-6 second pauses during atrial fibrillation episodes and greater than 1 second pauses during sinus rhythm. Clinical Decision Making Due to the patient's need for both a pacemaker and an atrial fibrillation ablation, the electrophysiologist felt the patient would be high risk for atrial lead dislodgment. Another concern was the patient's long-term anticoagulation secondary to his mechanical aortic valve. After a multidisciplinary discussion, the consensus was for a Micra pacemaker to be inserted with atrial fibrillation ablation to be performed shortly after. This was performed successfully and in outpatient follow up, the patient has been free of any further syncope, dizziness or atrial fibrillation. Conclusions This case focuses on creating awareness that Micra transcatheter pacing can be utilized in high risk patients with excellent results in an ever-expanding list of clinical indications.

A technique to prevent recurrence after the repair of pacemaker lead-induced tricuspid regurgitation.

This article describes how to repair pacemaker lead-induced tricuspid regurgitation without removing the pacing leads. Our technique can eliminate the lead contact with the tricuspid leaflets and the tricuspid apparatus and is effective in preventing recurrence.

GW29-e1164 Clinical Utility of Real-time Three-Dimensional Echocardiography in the Evaluation of Lead-Induced Tricuspid Regurgitation

This study sought to identify the feasibility of evaluating the factors that worsen Lead-induced tricuspid regurgitation (LITR) and quantify tricuspid regurgitation severity by Real-time Three-Dimensional Echocardiography (RT-3DE). The subjects were a cohort of 128 consecutive patients who had

GW28-e1071 Clinical Utility of Real-time Three-Dimensional Echocardiography in the Evaluation of Lead-Induced Tricuspid Regurgitation

GW28-e1071 Clinical Utility of Real-time Three-Dimensional Echocardiography in the Evaluation of Lead-Induced Tricuspid Regurgitation

Tricuspid regurgitation after implantable cardioverter-defibrillator implantation in patients with arrhythmogenic right ventricular cardiomyopathy

Introduction. The problem of lead-induced tricuspid regurgitation (LITR) in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) is poorly investigated. Patients with high risk of adverse outcome usually receive implantable cardioverter-defibrillator (ICD) as a prevention of sudden cardiac death (SCD). nfortunately, the insertion of ICD into the right ventricle is supposed to exacerbate tricuspid regurgitation. As ICD (or cardiac resynchronization therapy defibrillator) seems to be necessity in prevention of SCD in quite large group of patients, we aimed to evaluate frequency of LITR and further outcome in these persons. Material and methods. In a database of 55 patients with ARVC and ICD implanted in prevention of SCD, we selected 35 patients (mean age 48.78 ± 13.56 years) with data suitable for analysis. Based on the results of echocardiography, study population was divided into 2 groups: TR+ group with worsening of tricuspid regurgitation (TR) defined as its deterioration to higher grade and TR– group (without worsening of TR). Results. In 65.71% of patients TR worsened after ICD implantation. Mean time of observation was 91.06 ± 55.32 months. In TR+ group, 2 patients (8.7%) died because of heart failure and 1 patient died in a traffic accident. In TR– group 1 patient (8.33%) died because of heart failure and 1 patient had heart transplantation (results were statistically insignificant). Conclusions. We couldn’t prove that the worsening of TR was associated with worsening of clinical outcome. Further studies are needed to assess an influence of LITR on prognosis in patients with ARVC and ICD implanted.

Clinical utility of three-dimensional echocardiography in the evaluation of tricuspid regurgitation induced by implantable device leads.

Implantable device leads could cause tricuspid regurgitation (TR) by interfering with leaflet motion. This study evaluated the feasibility of using three-dimensional transthoracic echocardiography (3DTTE) to identify lead-induced tricuspid regurgitation (LITR). 3DTTE full-volume images of the right ventricle (RV) and zoomed images of the tricuspid valve were obtained in 207 patients with implanted devices, and the images were analyzed. TR severity was estimated based on measurements of the proximal isovelocity surface area (PISA) radius. 3DTTE clearly identified the course and position of the leads in 74% of the patients. The lead tips were located in the RV apex or outflow tract in 95% of patients and in the interventricular septum (IVS) in 5% of patients. At the tricuspid annular level, 25% of leads were impinging on a leaflet, 41% were located in the commissure of two leaflets, and 34% were in the middle of the tricuspid orifice. 3D images revealed that when the lead tip was in the IVS or the lead was impinging on a leaflet, the device lead was more likely to interfere with leaflet mobility (P<.05). Interfering leads were associated with more significant TR than noninterfering leads (P<.05). 3DTTE showed a clear association between lead interference and TR worsening after lead placement. 3DTTE guidance should be considered for the placement of leads.

Percutaneous tricuspid valvotomy for pacemaker lead-induced tricuspid stenosis

Permanent pacemaker lead-induced tricuspid regurgitation is extremely uncommon. We report a patient with severe tricuspid stenosis detected 10 years after permanent single chamber pacemaker implantation in surgically corrected congenital heart disease. The loop at the level of the tricuspid valve may have caused endothelial injury and eventually led to stenosis. Percutaneous balloon valvotomy for such stenosis has not been reported from India.

Effect of Right Ventricular Pacing on Right Ventricular Mechanics and Tricuspid Regurgitation in Patients With High-Grade Atrioventricular Block and Sinus Rhythm (from the Protection of Left Ventricular Function During Right Ventricular Pacing Study)

Right ventricular (RV) pacing has been linked with lead-induced tricuspid regurgitation (TR), left ventricular (LV) dysfunction, and dyssynchrony, but the effect of pacing on RV function is unclear. We sought to investigate the effect of pacing on RV synchrony, RV function, and TR, and their association with LV function. In this substudy of the PROTECT-PACE (Protection of left ventricular function during right ventricular pacing) study of the effects of RV pacing in patients with preserved ejection fraction, 145 patients (76 RV apex and 69 non-RV apex pacing) had measurable RV parameters. We assessed tricuspid annular plane systolic excursion (TAPSE), time difference between peak TAPSE and peak mitral annular plane systolic excursion (TM-APSE-dif), global LV longitudinal strain, E/e', TR vena contracta, and TR peak gradient. Echocardiography was performed just after implantation and at 2 years. TR parameters significantly worsened after 2 years, but pacing site was not associated with changes in RV and TR parameters. No temporal change in TAPSE and TM-APSE-dif was observed overall, but worsening of TM-APSE-dif was associated with worsening TAPSE. Global longitudinal strain and E/e' both deteriorated over 2 years; these changes were significantly associated. In a multivariate regression, worsening global longitudinal strain and worsening TM-APSE-dif were significantly associated with deterioration of TAPSE. Furthermore, increased E/e' and its deterioration were associated with worsening TR vena contracta and TR peak gradient, respectively. Decreased TAPSE was also associated with deterioration of TR vena contracta. In conclusion, RV pacing appears to worsen TR, an effect which might be caused by elevated LV filling pressure due to LV dysfunction. In this study, RV pacing did not affect RV function during 2-year follow-up, but such an effect might occur if RV dyssynchrony or LV dysfunction occurred after pacing. The effect of RV pacing site on RV and TR mechanics was minor.

Significant lead-induced tricuspid regurgitation is associated with poor prognosis at long-term follow-up

BackgroundAlthough the presence of an RV lead is a potential cause of tricuspid regurgitation (TR), the clinical impact of significant lead-induced TR is unknown.ObjectiveTo evaluate the effect of significant lead-induced...

Significant lead-induced tricuspid regurgitation is associated with poor prognosis at long term follow-up

Background: The presence of a right ventricular (RV) lead is a potential cause of tricuspid regurgitation (TR). However, the clinical impact of significant lead-induced TR is not yet elucidated. We aimed at evaluating the effect of significant lead-induced TR on 1) cardiac performance and 2) long-term outcome of patients with cardioverter-defibrillator or pacemaker. Methods: A total of 239 cardioverter-defibrillator (n=191) or pacemaker (n=48) recipients (age 60±14 years, 77% male), with an echocardiographic evaluation before and within 1-1.5 years after device implantation, were included. Lead-induced significant TR was defined as a TR worsening and reaching a grade ≥2 at follow-up echocardiography. During long-term follow-up (median 58, IQR 35-76 months) all-cause mortality and heart failure related events were recorded. Results: Before device implantation, most patients had TR grade 1 or 2 (64%) or no TR (34%), but after lead placement, significant TR was observed in 91 patients (38%). Changes in cardiac chambers size and function at follow-up were similar between patients with and without significant lead-induced TR, except for increased RV diastolic area (17±6 vs. 16±5, p=0.009), right atrial diameter (39±10 vs. 36±8mm, p<0.001) and pulmonary arterial pressures (41±15 vs. 33±10mmHg, p<0.001) in patients with significant lead-induced TR. Patients with significant lead-induced TR showed worse long-term outcome in terms of overall survival (p=0.038) and/or combined with heart failure related events (p=0.017). At multivariate analysis, significant lead-induced TR was independently associated with all-cause mortality (HR 1.75, 95% CI: 1.01-3.04, p=0.047) together with age, LV ejection fraction and RV pacing percentage. ![Figure][1] Overall survival Conclusion: Lead-induced significant TR is associated with long-term poor prognosis. [1]: pending:yes

Effects of tricuspid valve regurgitation on clinical and echocardiographic outcome in patients with cardiac resynchronization therapy

The severity of tricuspid regurgitation (TR) is a predictor of outcome among heart failure patients. The interaction between cardiac resynchronization therapy (CRT) and TR has not been described. In this study, we examined the effect of pre-implant TR, and worsened TR post-implant, on response to CRT and overall survival. We included all patients with successfully implanted CRT systems between 2007 and 2010. Patients were divided into two groups pre-implant: (Gp 1) no-or-mild TR; and (Gp 2) moderate-or-severe TR. Post-implant, patients were divided into two groups: (Gp A) improved or stable TR; and (Gp B) worsened TR. The clinical and echocardiographic outcome of all patients was assessed. The study included 193 patients. Thirty-five subjects (18%) had moderate or severe TR pre-implant (Gp 2). Baseline echo parameters and 6 min walk distance were worse in Gp 2 compared with Gp 1 (mild or no TR). There was no significant difference in clinical response to CRT between the two groups. However, Gp 2 had a significantly lower echocardiographic response (35 vs. 60%, P = 0.01) and higher mortality over 3 years (OR = 6.70, 95% CI = 1.8-24.5, P = 0.004). Post-implant, 25 patients (13%) developed worsened TR (Gp B), not associated with deterioration in right ventricle function or elevation in pulmonary artery pressure. Worsened TR predicted a reduced clinical response to CRT (42 vs. 70%, P = 0.006), when compared with Gp A. The presence of baseline moderate or severe TR is associated with increased mortality but does not predict clinical or echocardiographic response to CRT. Patients with worsened TR following CRT are less likely to clinically respond to CRT. Pacing leads passing through the tricuspid valve may worsen TR. It is conceivable that avoidance of lead-induced TR by alternative implantation techniques could improve the response rate to CRT.