Impact of Implantable Transvenous Device Lead Location on Severity of Tricuspid Regurgitation

Abstract

Background Implantable device leads can cause tricuspid regurgitation (TR) when they interfere with leaflet motion. The aim of this study was to determine whether lead-leaflet interference is associated with TR severity, independent of other causative factors of functional TR. Methods A total of 100 patients who underwent transthoracic two-dimensional and three-dimensional (3D) echocardiography of the tricuspid valve before and after lead placement were studied. Lead position was classified on 3D echocardiography as leaflet-interfering or noninterfering. TR severity was estimated by vena contracta (VC) width. Logistic regression analysis was used to identify factors associated with postdevice TR, including predevice VC width, right ventricular end-diastolic and end-systolic areas, fractional area change, right atrial size, tricuspid annular diameter, TR gradient, device lead age, and presence or absence of lead interference. Odds ratios were used to describe the association with moderate (VC width ≥ 0.5 cm) or severe (VC width ≥ 0.7 cm) TR, separately, using bivariate and stepwise multivariate logistic regression analysis. Results Forty-five of 100 patients showed device lead tricuspid valve leaflet interference. The septal leaflet was the most commonly affected (23 patients). On bivariate analysis, preimplantation VC width, right atrial size, tricuspid annular diameter, and lead-leaflet interference were significantly associated with postdevice TR. On multivariate analysis, preimplantation VC width and the presence of an interfering lead were independently associated with postdevice TR. Furthermore, the presence of an interfering lead was the only factor associated with TR worsening, increasing the likelihood of developing moderate or severe TR by 15- and 11-fold, respectively. Conclusion Lead-leaflet interference as seen on 3D echocardiography is associated with TR after device lead placement, suggesting that 3D echocardiography should be used to assess for lead interference in patients with significant TR.

Long-term right ventricular implantable cardioverter-defibrillator lead performance in arrhythmogenic right ventricular cardiomyopathy

“…28 However, lead location has not been shown to affect tricuspid regurgitation 29 but use of 3D echocardiography to evaluate the etiology of tricuspid regurgitation may be useful. 29,30 3D echocardiography may also aid in determining torque force of the patients ventricle, 31 unfortunately this sophisticated imaging was not performed. Furthermore, subcutaneous ICD (S-ICD) may eliminate the risk of tricuspid regurgitation associated with endovascular leads.…”

Severe tricuspid regurgitation due to interactions with right ventricular permanent pacemaker or defibrillator leads

“…Multiple case reports have described patients with intracardiac devices in whom adverse lead‐TV interactions were well described with the addition of 3D assessment . Data from retrospective case series suggest that in 74–94% of 2D studies with adequate windows, 3D images are able to clearly define the position of a device lead as it passes through the level of the tricuspid annulus, with a high degree of agreement between interpreters . Although based primarily on retrospective data, clarifying lead positioning has significant implications: leads positioned over and/or pinning a leaflet (predominantly septal or posterior) are predictive of TR, as opposed to leads which pass through the middle of the valve or in the commissures (predominantly posteroseptal) .…”

“…Data from retrospective case series suggest that in 74–94% of 2D studies with adequate windows, 3D images are able to clearly define the position of a device lead as it passes through the level of the tricuspid annulus, with a high degree of agreement between interpreters . Although based primarily on retrospective data, clarifying lead positioning has significant implications: leads positioned over and/or pinning a leaflet (predominantly septal or posterior) are predictive of TR, as opposed to leads which pass through the middle of the valve or in the commissures (predominantly posteroseptal) . This modality has even been used to assess the degree of fibrosis involving the lead and leaflet tissue (confirmed by surgery), which has significant implications for the options for lead extractions …”

Clinical Application of 3-Dimensional Echocardiography in the USA

“…Multiple publications have reported the usefulness of 3D echocardiography for detecting the location of the lead and its association with significant TR. [155][156][157][158] In one of those studies, 45 of 100 patients showed device lead TV leaflet interference. The septal leaflet was the that provides an accurate and reliable quantitative assessment of AS.…”

“…The authors concluded that lead-leaflet interference as seen on 3D echocardiography is associated with TR after device lead placement, suggesting that 3D echocardiography should be used to assess lead interference in patients with significant TR. 156 Fukuda et al used 3D echocardiography to reveal that one of the causes of secondary or functional TR was dilation and flattening of the tricuspid annulus. 159 In another clinical 3D echocardiographic study of 54 patients with various degrees of functional TR, septal leaflet tethering, septal-lateral annular dilatation, and the severity of pulmonary hypertension were the main determinants of TR severity.…”