Predictors of worsening TR severity after right ventricular lead placement: any added value by post-procedural fluoroscopy versus three –dimensional echocardiography?

Abstract

Background The effect of right ventricular (RV) leads on tricuspid valve has been already raised concerns, especially in terms of prognostic implication. For such assessment, three-dimensional transthoracic echocardiography (3D-TTE) has been used previously but there was no data on the use of post-procedural fluoroscopy in the literature. Methods We prospectively enrolled 59 patients who underwent clinically indicated placement of pacemaker or implantable cardioverter defibrillator (ICD). Vena contracta (VC) and tricuspid regurgitation (TR) severity were measured using two-dimensional transthoracic echocardiography (2D-TTE) at baseline. Follow up 3D-TTE was performed 6 months after device implantation to assess TR severity and RV lead location. Results Lead placement position in TV was defined in 51 cases.TR VC was increased after the lead placement, compared to the baseline study (VC: 3.86 ± 2.32 vs 3.18 ± 2.39; p = 0.005), with one grade worsening in TR in 25.4% of cases. The mean changes in VC levels were 1.14 ± 0.67 mm. Among all investigated parameters, VC changes were predicted based on lead placement position only in 3D-TTE (p < 0.001) while the other variables including fluoroscopy parameters were not informative. Conclusion The RV Lead location examined by 3D-TTE seems to be a valuable parameter to predict the changes in the severity of the tricuspid regurgitation. Fluoroscopy findings did not improve the predictive performance, at least in short term follow up.

Tricuspid Regurgitation (TR) after Implantation of a Cardiac Implantable Electronic Device (CIED)—One-Year Observation of Patients with or without Left Ventricular Dysfunction

“…The general progression of TR by one grade in our study was 34.6% and by two or more grades, 15.8%, which is consistent to previous studies [ 3 , 4 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 ]. The progression of TR in group 1 was an effect of TR progression by one grade (43.3% vs. 21.9%, p = 0.033), which was mostly gained by the change from none/trace to mild (31.7%) ( Table 4 ).…”

“…Notwithstanding, in this study, there was no difference in TR occurrence between the groups, which is consistent with other authors [ 7 , 8 , 9 , 10 , 11 , 21 , 30 ]. Yu et al observed that when the pacing lead is located in the RV apex, it is more likely to affect the posterior leaflet [ 36 ], and some authors suggest that the septal and posterior leaflets are the most affected by the leads, despite the pacing lead localization [ 7 , 14 , 15 , 23 , 24 , 29 , 31 , 34 ]. However, contrary to this, Cheng et al [ 31 ] found that a significant increase in the PISA radius of TR after implantation of CIED was observed more often in the group with lead tips in the IVS.…”

“…Lead-related tricuspid regurgitation (LRTR) appears to be an important complication in patients with cardiac implantable electronic devices (CIED) [ 3 , 4 , 5 , 6 ]. The frequency of significant TR development after CIED implantation is not precisely determined and varies from 7.2% to 44.7% [ 3 , 4 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 ] depending on the criteria used. CIEDs may directly affect the function and structure of the tricuspid valve [ 3 , 7 , 8 , 12 , 14 , 24 , 29 , 31 , 32 , 33 , 34 , 35 ].…”

“…Rajappan suggests that “direct crossing” results in decreased risk of damage to the tricuspid valve apparatus [ 43 ]. Furthermore, the position of the lead in the center of the tricuspid orifice [ 7 , 24 , 31 , 44 ] or in the commissures prevents restriction of leaflet motion [ 7 , 23 , 24 , 29 , 31 , 45 ]. Some authors suggest that the septal and the posterior leaflets are the most affected by the leads [ 7 , 14 , 15 , 23 , 24 , 29 , 31 , 34 ].…”

“…Furthermore, the position of the lead in the center of the tricuspid orifice [ 7 , 24 , 31 , 44 ] or in the commissures prevents restriction of leaflet motion [ 7 , 23 , 24 , 29 , 31 , 45 ]. Some authors suggest that the septal and the posterior leaflets are the most affected by the leads [ 7 , 14 , 15 , 23 , 24 , 29 , 31 , 34 ]. As TR is associated with increased mortality [ 1 , 4 , 11 , 12 , 30 , 32 ] and the development of right ventricle (RV) failure [ 10 , 12 , 15 , 18 , 30 , 37 ], the aim of that study was a determination of TR progression after CIED implantation in patients with preserved-, mildly-, and severely reduced ejection fraction (EF), as well as tracking freedom from heart failure (HF) exacerbation and death-free survival among patients with LRTR, depending on left ventricle function, in a one-year observation.…”