clinicaltrials.gov Identifier: NCT01313169.

Estimates of the prevalence and importance of significant tricuspid regurgitation (STR) related to implantable device leads are based mainly on case reports, small observational studies or mixed samples that include defibrillators. We sought to assess whether patients with permanent pacemaker (PPM) leads have an increased risk of STR and to determine mortality associated with PPM-related TR in a large longitudinal single-center cohort. We examined the prevalence of STR (defined as moderate-severe or ≥ 3+) among all echocardiograms performed between 2005 and 2011 excluding those with defibrillators. We then examined mortality risk according to the prevalence of PPM and STR after adjusting for cardiac co-morbidities, left ventricular (LV) systolic/diastolic function, and pulmonary artery hypertension. We screened 93592 echocardiograms (1245 with PPM) among 58556 individual patients (634 with PPM). The prevalence of STR was higher in patients following PPM placement (mean age 79 ± 3 years; 54% males) compared to patients without a PPM (adjusted odds ratio 2.32, 95% confidence interval [CI], 1.54–3.49; p<0.0001). Among patients with a PPM lead, the presence of STR was associated with increased mortality (adjusted hazard ratios [HR] 1.40, 95% CI 1.04–2.11, p=0.027 versus no STR). Compared to having neither a PPM lead nor STR, adjusted HR for death were 2.13 (95% CI, 1.93–2.34) for STR but no PPM, 1.04 (0.89–1.22) for PPM without STR, and 1.55 (1.13–2.14) for PPM with STR. In conclusion, in a sample comprising over 58,000 individual patients, PPM leads are associated with higher risk of STR after adjustment for LV systolic/diastolic function and pulmonary artery hypertension; similarly to STR from other cardiac pathologies, PPM-related STR is associated with increased mortality.

Physicians in general, and psychiatrists in particular, know the standard for competence but may apply it incorrectly. This suggests that the common clinical practice of relying on expert medical opinion may introduce bias and produce inaccurate results that undermine patient autonomy.