Tricuspid valve disease and cardiac implantable electronic devices

Abstract

The role of cardiac implantable electronic device (CIED)-related tricuspid regurgitation (TR) is increasingly recognized as an independent clinical entity. Hence, interventional TR treatment options continuously evolve, surgical risk assessment and peri-operative care improve the management of CIED-related TR, and the role of lead extraction is of high interest. Furthermore, novel surgical and interventional tricuspid valve treatment options are increasingly applied to patients suffering from TR associated with or related to CIEDs. This multidisciplinary review article developed with electrophysiologists, interventional cardiologists, imaging specialists, and cardiac surgeons aims to give an overview of the mechanisms of disease, diagnostics, and proposes treatment algorithms of patients suffering from TR associated with CIED lead(s) or leadless pacemakers.

Keywords: Cardiac implantable electronic device; Lead related; Pacemaker; Tricuspid regurgitation.

Graphical Abstract

Definition of TR in the presence of a CIED lead. CIED, cardiac implantable electronic device; TR, tricuspid regurgitation.

Figure 1

Prevalence of cardiac implantable electronic device-associated tricuspid regurgitation in several studies. CIED, cardiac implantable electronic device; TR, tricuspid regurgitation.

Figure 2

Mechanisms of cardiac implantable electronic device-related tricuspid regurgitation. CIED, cardiac implantable electronic device; RV, right ventricle; TLE, transvenous lead extraction; TV, tricuspid valve.

Figure 3

Surgical situ in a patient with lead-related tricuspid regurgitation. (A) Device lead attached to the tricuspid valve in echocardiography; (B) intra-operative view of an attached cardiac implantable electronic device lead; and (C) device lead attached to the tricuspid valve and the subvalvular apparatus with significant ingrowth.

Figure 4

Risk factors of cardiac implantable electronic device-related tricuspid regurgitation. AF, atrial fibrillation; PHT, pulmonary hypertension; RV, right ventricle; TV, tricuspid valve.

Figure 5

Risk of lead-associated tricuspid regurgitation after pacemaker implantation. CI, confidence interval; HR, hazard ratio; n = number; OR, odds ratio; RV, right ventricle; TR, tricuspid regurgitation (open license for re-print).

Figure 6

Imaging algorithm for patients undergoing cardiac implantable electronic device implantation or transvenous lead extraction. CIED, cardiac implantable electronic device; TEE: transoesophageal echocardiography; TLE, transvenous lead extraction; TR: tricuspid regurgitation; TTE, transthoracic echocardiography; TV, tricuspid valve.

Figure 7

Example of a lead-related tricuspid regurgitation with ‘tricuspid kick’ and impingement of the posterior leaflet. Severe lead–leaflet interaction with impingement of the posterior leaflet resulting in severe cardiac implantable electronic device-related tricuspid regurgitation. (A) Impingement of the posterior leaflet; (B) severe tricuspid regurgitation with large coapation gap and secondary leaflet tethering; (C) excessive slack with visible tricuspid kick as a sign of potential interaction with the tricuspid annulus; and (D) cardiac computed tomography shows interaction with the tricuspid valve annulus (reconstructed line), as well as excessive slack in the right ventricle. RA, right atrium; RV, right ventricle.

Figure 8

Treatment algorithm of cardiac implantable electronic device-related tricuspid regurgitation. CAVI, caval valve implantation; ICD, implantable cardioverter defibrillator; TEER, transcatheter edge-to-edge repair; TLE, transvenous lead extraction; TR, tricuspid regurgitation; TTVR, transcatheter tricuspid valve replacement.

Figure 9

Treatment algorithm of cardiac implantable electronic device-associated tricuspid regurgitation. ICD, implantable cardioverter defibrillator; TEER, transcatheter edge-to-edge repair; TLE: transvenous lead extraction; TR, tricuspid regurgitation; TTVR, transcatheter tricuspid valve replacement.

Figure 10

Examples of lead jailing during trancatheter tricuspid valve interventions. Examples of pacemaker lead jailing during transcatheter valve replacement with the EVOQUE system (A) and direct transcatheter tricuspid annuloplasty with the Cardioband system (B and C). In both cases, no lead dysfunction was detected up to 2 years after the procedure.

Figure 11

Peri-interventional lead management during tricuspid interventions. ICD, implantable cardioverter defibrillator; LCPM, leadless cardiac pacemaker; PPM, permanent pacemaker; RV, right ventricle; s/p, status post; TEE, transoesophageal echocardiography; TEER, transcatheter edge-to-edge repair; TV, tricuspid valve.

Figure 12

Examples of valve-sparing pacing strategies in the context of transcatheter tricuspid valve replacement. (A) Pre-emptive implantation of a LCPM before transcatheter tricuspid valve replacement with the EVOQUE system in a patient with a complete atrioventricular block during right heart catheterization. The position of the LCPM needs to be carefully chosen; (B) transoesophageal echocardiography guiding of coronary sinus lead implantation (white arrow) after transcatheter tricuspid valve replacement with the LUX valve; (C) sinus angiography highlighting potential interaction between the bioprosthesis and the coronary sinus; and (D) final pacemaker lead (white arrow) placement into the coronary sinus. CS, coronary sinus.