Evolution and prognosis of tricuspid and mitral regurgitation following cardiac implantable electronic devices: a systematic review and meta-analysis

Abstract

Aims: Significant changes in tricuspid regurgitation (TR) and mitral regurgitation (MR) post-cardiac implantable electronic devices (CIEDs) are increasingly recognized. However, uncertainty remains as to whether the risk of CIED-associated TR and MR differs with right ventricular pacing (RVP) via CIED with trans-tricuspid RV leads, compared with cardiac resynchronization therapy (CRT), conduction system pacing (CSP), and leadless pacing (LP). The study aims to synthesize extant data on risk and prognosis of significant post-CIED TR and MR across pacing strategies.

Methods and results: We searched PubMed, EMBASE, and Cochrane Library databases published until 31 October 2023. Significant post-CIED TR and MR were defined as ≥ moderate. Fifty-seven TR studies (n = 13 723 patients) and 90 MR studies (n = 14 387 patients) were included. For all CIED, the risk of post-CIED TR increased [pooled odds ratio (OR) = 2.46 and 95% CI = 1.88-3.22], while the risk of post-CIED MR reduced (OR = 0.74, 95% CI = 0.58-0.94) after 12 and 6 months of median follow-up, respectively. Right ventricular pacing via CIED with trans-tricuspid RV leads was associated with increased risk of post-CIED TR (OR = 4.54, 95% CI = 3.14-6.57) and post-CIED MR (OR = 2.24, 95% CI = 1.18-4.26). Binarily, CSP did not alter TR risk (OR = 0.37, 95% CI = 0.13-1.02), but significantly reduced MR (OR = 0.15, 95% CI = 0.03-0.62). Cardiac resynchronization therapy did not significantly change TR risk (OR = 1.09, 95% CI = 0.55-2.17), but significantly reduced MR with prevalence pre-CRT of 43%, decreasing post-CRT to 22% (OR = 0.49, 95% CI = 0.40-0.61). There was no significant association of LP with post-CIED TR (OR = 1.15, 95% CI = 0.83-1.59) or MR (OR = 1.31, 95% CI = 0.72-2.39). Cardiac implantable electronic device-associated TR was independently predictive of all-cause mortality [pooled hazard ratio (HR) = 1.64, 95% CI = 1.40-1.90] after median of 53 months. Mitral regurgitation persisting post-CRT independently predicted all-cause mortality (HR = 2.00, 95% CI = 1.57-2.55) after 38 months.

Conclusion: Our findings suggest that, when possible, adoption of pacing strategies that avoid isolated trans-tricuspid RV leads may be beneficial in preventing incident or deteriorating atrioventricular valvular regurgitation and might reduce mortality.

Keywords: Cardiac resynchronization therapy; Conduction system pacing; Implantable cardioverter defibrillator; Leadless pacemaker; Mitral regurgitation; Pacemaker; Tricuspid regurgitation.

Graphical Abstract

Figure 1

Pooled odds ratio (OR) and 95% confidence interval (95% CI) of significant tricuspid regurgitation (≥ moderate TR) post-CIED compared with pre-CIED implantation for all devices combined. CIED, cardiac implantable electronic device.

Figure 2

Pooled odds ratio (OR) and 95% confidence interval (95% CI) of significant mitral regurgitation (≥ moderate MR) post-CIED compared with pre-CIED implantation for all devices combined. CIED, cardiac implantable electronic device.

Figure 3

Risk of significant tricuspid regurgitation (≥ moderate TR) post-transvenous right ventricular pacing via CIED trans-tricuspid right ventricular leads compared with pre-CIED implantation [pooled odds ratio and 95% confidence interval (95% CI)]. CIED, cardiac implantable electronic device.

Figure 4

Risk of significant mitral regurgitation (≥ moderate MR) post-transvenous right ventricular pacing via CIED with trans-tricuspid RV leads compared with pre-CIED implantation (pooled odds ratio and 95% confidence interval). CIED, cardiac implantable electronic device.

Figure 5

Tricuspid regurgitation post-conduction system pacing. (A) Odds ratio for studies that provided binary data and (B) standardized mean difference (SMD) for studies that provided continuous data. HBP, His bundle pacing; LBBP, left bundle branch pacing.

Figure 6

Mitral regurgitation post-conduction system pacing. (A) Odds ratio for studies that provided binary data and (B) standardized mean difference (SMD) for studies that provided continuous data. HBP, His bundle pacing; LBBP, left bundle branch pacing.

Figure 7

Risk of significant tricuspid regurgitation (TR) (A) and secondary mitral regurgitation (MR) (B) post-cardiac resynchronization compared with pre-cardiac resynchronization therapy (CRT).

Figure 8

Risk of tricuspid regurgitation (TR) (A) and mitral regurgitation (MR) (B) after leadless permanent pacemaker implantation.

Figure 9

Pooled hazard ratio (95% confidence interval) of all-cause mortality associated with presence vs. absence of persistent significant tricuspid regurgitation post-all cardiac implantable electronic devices (CIEDs) (A) and secondary mitral regurgitation post-cardiac resynchronization therapy (CRT) (B).