Curr Heart Fail Rep DOI 10.1007/s11897-014-0249-x


Tricuspid Valve Incompetence Following Implantation of Ventricular Leads Giselle A. Baquero & Jerry Luck & Gerald V. Naccarelli & Mario D. Gonzalez & Javier E. Banchs

# Springer Science+Business Media New York 2014

Abstract Most cardiovascular implantable electronic devices (CIEDs) require a ventricular lead to be placed across the tricuspid valve. Tricuspid regurgitation (TR) is an understudied clinical complication of right ventricular lead implantation and its clinical significance is unknown. We review the incidence, predictors, and current management of TR as a complication of ventricular lead implantation. Emerging technologies, including leadless pacing devices and subcutaneous systems, offer the benefit of little or none tricuspid valve disruption.

Keywords Tricuspid valve incompetence . Ventricular leads . Cardiovascular implantable electronic devices

This article is part of the Topical Collection on Management of Heart Failure G. A. Baquero (*) : J. Luck : G. V. Naccarelli : M. D. Gonzalez Division of Cardiology, Department of Medicine, Penn State College of Medicine, Penn State Hershey Heart and Vascular Institute, Penn State University, 500 University Drive. Mail Code H047, PO BOX 850, Hershey, PA 17033, USA e-mail: [email protected] J. Luck e-mail: [email protected] G. V. Naccarelli e-mail: [email protected] M. D. Gonzalez e-mail: [email protected] J. E. Banchs Baylor Scott and White Health Central, Scott and White Memorial Hospital, Temple, TX, USA e-mail: [email protected]

Introduction Implantation of cardiovascular implantable electronic devices (CIEDs) including dual-chamber permanent pacemakers (PPM), implantable cardioverter-defibrillators (ICDs), and cardiac resynchronization therapy (CRT) devices require an endocardial ventricular lead to be placed across the tricuspid valve. The association between placement of these devices and tricuspid valve regurgitation (TR) has not been extensively studied, and the prevalence and severity of this complication have not been clinically recognized. To date, published data on the frequency of device-related TR are conflicting with some authors reporting it as a rare phenomenon [1–5] and only a few recent studies reporting a more realistic larger occurrence [6•, 7–13, 14••]. In the following manuscript, we review the current available literature on the prevalence and severity of TR after implantation of CIED, the mechanisms involved in the development of TR among these patients and possible predicting factors of this under-recognized complication.

Lead Implantation The implantation of most CIED requires an endocardial ventricular lead to be placed across the tricuspid valve. The procedure is performed under fluoroscopy, and different techniques are used to position the leads within the right ventricle (RV) aiming to direct the tip of the lead to the right ventricular apex, interventricular septum, or right ventricular outflow tract. Many different techniques not mutually exclusive have been described. The steerability of the lead depends on its architecture, shape, and stiffness of the stylet used. It has been described that to cross the tricuspid valve, the stylet must be curved to facilitate passage. The technique used to cross the tricuspid valve (TV) and position the RV lead will depend on

Curr Heart Fail Rep

the operator’s training and experience. The lead placement may be achieved by prolapsing the lead across the TV by first looping it in the right atrium, then pushing the loop forward with the stylet until it falls through the valve, crossing the valve directly, aiming toward the target location with a shaped stylet in place, or crossing the valve directly toward the right ventricle outflow tract with a curved stylet in place, then retracting the lead until it is aimed at the target location [15], among other techniques. Determining the lead position at the level of the tricuspid valve annulus with respect to the leaflets is difficult because the tricuspid valve leaflets are not seen on fluoroscopy. Three-dimensional transesophageal echocardiography shows detailed visualization of the TV anatomy from both the atrial and ventricular perspectives, including simultaneous visualization of all three tricuspid valve leaflets and has been proven to demonstrate a clear association between lead anatomical position and TR; however, this imaging modality is not routinely used during CIED placement [16••].

Lead-Related TR Tricuspid regurgitation is a common echocardiographic finding [16••], often considered a well-tolerated and benign condition in its early stages. Although, when associated with significant pulmonary hypertension or either right or left ventricular dysfunction, it has been linked to increased morbidity and mortality, as a consequence of worsening right heart failure [17–19]. On the same line, moderate TR may have a worse prognosis, even in the absence of ventricular dysfunction or pulmonary hypertension with a reduced 1-year survival of 65 to 80 % [20]. Therefore, identification of CIED-lead interference with normal tricuspid valve function leading to TR is important for the prognosis and guidance of therapy in these patients. The prevalence of this complication has not been systematically studied, and available data remains mostly retrospective and conflicting with early animal and human studies asserting that the development of new TR after implantation of a CIED was rare, with no significant difference in the severity of TR pre- and post-endocardial lead implantation [1–5] and other authors reporting that this complication may be frequent, suggesting an increase in TR severity after CIED implantation [6•, 7–13, 14••]. A previous experimental study in four dogs, conducted to evaluate the feasibility of transvenous cardiac pacing in the fetus with complete heart block associated with hydrops, demonstrated no significant tricuspid valve regurgitation after placement of the pacing lead [1]. In a retrospective study of 20 patients using inferior vena cava contrast reflux during systole as a marker of TR, Morgan et al. [2] reported no association between TR and ventricular demand pacing. However, the

study was limited by the small sample size and prolonged period of time elapsed between the implantation date and postimplantation echocardiogram (mean 52 months). Kucukarslan et al. [3] in a retrospective analysis of 61 patients concluded that new or worsening TR is rare after PPM implantation. One of the limitations noted from their work was the short period of time elapsing from the implantation date to the follow-up echocardiogram (mean 1±1 days). Leibowitz et al. [4] exposed similar findings in a small prospective study of 35 patients suggesting that the degree of TR did not change after PPM or ICD implantation. However, major limitations included that the pertinent echocardiograms were obtained within a short time after device implantation (mean 1.2 days) and there was no statistical comparison of the grades of TR before and after device placement. Results of a study by Webster et al. [5] with a larger sample of 123 pediatric patients found a minimal, but statistically significant change in TR, suggesting that there is little impact of transvenous leads on TR in growing children or patients with right-sided structural heart disease. On the other hand, Al-Mohaissen et al. reported in their series that the prevalence of TR after CIED placement may range between 7 and 39 % [6•]. The largest prevalence of confirmed CIEDrelated TR reported to date was 42 % back in 1987 by Sakai et al. [7]. Other studies that have reported an increased occurrence of TR related to ventricular leads include Panigua et al. [8] who found a higher prevalence of moderate to severe TR in patients with transvenous PPM compared to an age- and sex-matched control group. Lin et al. [9] in 2005 presented 41 patients with severe TR due to PPM or ICD lead placement requiring tricuspid valve surgery. Kim et al. [10] assessed the effect of trans-tricuspid placement of PPM and ICD leads on TR in 248 patients with echocardiograms before and after implant and reported development of TR in 21.2 % including severe TR developed in 3.9 % of patients with initially normal tricuspid valves. These findings led to the conclusion that TR worsening is more common with ICDs than PPMs among patients with baseline mild TR or less. Klustein et al. [11] in the largest cohort to date demonstrated increases of two or more grades of TR in 18.3 % of their study patients. Vaturi et al. [12] showed as well, worsening in TR severity in 18 of 23 patients. Alizadeh et al. [13] reported moderate TR in 10 patient prior to and 36 patients after device implantation. More recently, analysis of 148 patients that received a CIED by our group [14••] suggested development of TR in 25 % of patients and worsening TR from moderate to severe in 9 % of the study population. Further details regarding the findings and limitations of these case series are summarized in Table 1.

Mechanisms and Predictors of TR Development of TR after CIED implantation was observed to be more often in older patients with abnormal











Sakai et al.

Paniagua et al.

Leibowitz et al.

Lin et al.

Kucukarslan et al.

Webster et al.

Kim et al.

Klustein et al.

Vaturi et al.









18 pts 26 path reports from autopsies

Number of pts

CRMD-related TR study’s findings


Table 1


















Retrospective Case-control

Type of device

Study design

• Single-center experience

• There was>moderate TR in 7.2 % cases vs 1.7 % in controls (P

Tricuspid valve incompetence following implantation of ventricular leads.

Most cardiovascular implantable electronic devices (CIEDs) require a ventricular lead to be placed across the tricuspid valve. Tricuspid regurgitation...
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