Management of patients with transvalvular right ventricular leads undergoing transcatheter tricuspid valve interventions: a scientific statement of the European Heart Rhythm Association and the European Association of Percutaneous Cardiovascular Interventions of the ESC endorsed by the Heart Rhythm Society, the Asian Pacific Heart Rhythm Society and the Canadian Heart Rhythm Society

Abstract

Up to one-third of patients referred for transcatheter tricuspid valve intervention (TTVI) have a transvalvular pacemaker (PPM) or implantable cardioverter-defibrillator (ICD) lead in place. Both the electrophysiology and interventional cardiology communities have been alerted to the complexity of decision-making in this situation due to potential interactions between the leads and the TTVI material, including the risk of jailing or damage to the leads. This document, commissioned by the European Heart Rhythm Association and the European Association of Percutaneous Cardiovascular Interventions of the ESC, reviews the scientific evidence to inform Heart Team discussions on the management of patients with a PPM or ICD who are scheduled for or have undergone TTVI.

Keywords: Transcatheter tricuspid valve intervention; cardiac implantable electronic device lead; lead extraction; lead jailing; tricuspid regurgitation.

Graphical Abstract

Figure 1

Mechanisms of interaction between CIED lead and the tricuspid valve. (A) Example of leaflet perforation with the CIED lead piercing the septal leaflet (within the circle) and impairing its mobility. (B) Example of subvalvular apparatus damage during CIED lead positioning causing a flail septal leaflet (indicated by the arrow) due to chordal rupture and severe eccentric TR. (C) Example of impingement of the septal leaflet through a CIED lead (indicated by the arrow), limiting its systolic mobility and causing severe TR. A, anterior leaflet of the tricuspid valve; CIED, cardiac implantable electronic device; P, posterior leaflet of the tricuspid valve; RA, right atrium; RV, right ventricle; S, septal leaflet of the tricuspid valve; TR, tricuspid regurgitation.

Figure 2

Contemporary transcatheter treatment methods of tricuspid regurgitation and their interaction with CIED leads. (A) Transcatheter edge-to-edge repair; (B) Direct annuloplasty; (C) Transcatheter tricuspid valve replacement; (D) Heterotopic CAVI in both venae cavae.

Figure 3

Examples of interactions between tricuspid devices and CIED lead. (A–B) Implantation of 2 TriClips (*antero-septal coaptation line; **postero-septal coaptation line) with PM lead in-between (arrow); (C) Jailed PM lead after direct annuloplasty using the Edwards Cardioband system; (D–F) Interaction between the Lux valve and a jailed CIED RV lead as seen using echocardiography-fluoroscopy fusion imaging (D) and computed tomogram (E–F).

Figure 4

Main risks associated with lead jailing during transcatheter tricuspid valve interventions. CIED, cardiac implantable electronic device; ICD, implantable cardiac defibrillator; TLE, transvenous lead extraction; TR, tricuspid regurgitation; TTVI, transcatheter tricuspid valve intervention; TV, tricuspid valve.

Figure 5

A proposal to assist multidisciplinary discussion: red and orange flags for lead jailing—in these situations transvenous lead extraction requires careful multidisciplinary discussion before TTVI. (* see Table 3). CIED, cardiac implantable electronic device; ICD, implantable cardiac defibrillator; PM, pacemaker; TTVI, Transcatheter tricuspid valve intervention; TV, tricuspid valve.

Figure 6

Proposed algorithm for the management of TTVI candidates with symptomatic severe TR and a CIED lead crossing the TV. *Perform device interrogation and record underlying heart rhythm, paced/sensed event counters, arrhythmia history, battery and lead information (see also Table 6). **Red/orange flag(s) for lead jailing? PM dependency, ICD with previous therapy, multiple CIED leads crossing the TV, previous CIED infection, multiple risk factors for CIED infection, high lead tension (low slack) and/or leaflet impingement (in case of direct annuloplasty) (see also Figure 5). CIED, cardiac implantable electronic device; ICD, implantable cardiac defibrillator; RV, right ventricle; TLE, transvenous lead extraction; TR, tricuspid regurgitation; T-TEER, tricuspid transcatheter edge-to-edge repair; TTVI, transcatheter tricuspid valve intervention; TTVR, transcatheter tricuspid valve replacement; TV, tricuspid valve.

Figure 7

Example of valve-sparing implantation techniques after transcatheter tricuspid valve interventions. (A) Implantation of a LCPM after TTVR with delivery tool crossing the transcatheter transjugular LUX valve system (RAO). (B) Definitive position of the LCPM in the same case (not shown in this LAO projection, the LCPM is implanted away from the LUX valve system). (C) A pacing lead implanted in a coronary sinus branch after TEER. (D) Two pacing leads implanted in two distinct coronary sinus branches (PPM-dependent patient) after TTVR with the LUX valve system. LAO, left anterior oblique view; LCPM, leadless cardiac pacemaker; RAO, right anterior oblique view; TEER, transcatheter edge-to-edge repair; TTVR, transcatheter tricuspid valve replacement.

Figure 8

Proposed algorithm for the management of patients with a jailed RV CIED lead. CIED, cardiac implantable electronic device; LBB, left bundle branch; TTVR, transcatheter valve replacement; RV, right ventricle; TLE, transvenous lead extraction; TTVI, transcatheter tricuspid valve intervention.