The Importance of Tricuspid Regurgitation and Right Ventricular Overload in ICD/CRT Recipients: Beside the Left, beyond the Left

Abstract

Device therapy for advanced heart failure has become increasingly employed in the last 10 years. Several retrospective studies have postulated a harmful effect of implantable cardioverter‐defibrillator (ICD) lead placement on tricuspid valve function and right heart hemodynamics, in particular among patients with preexisting pulmonary vascular overload and both left and right ventricular remodeling/dysfunction. This functional hypothesis is also supported by long‐term clinical follow‐up analyses of ICD and cardiac resynchronization therapy recipients. In this viewpoint, we propose that the possibility of worsening tricuspid regurgitation and consequent hemodynamic deterioration following device implantation should be considered in future studies, as well as in the preimplant evaluation of individual candidates among other clinical factors. (PACE 2011; 34:1181–1184)

To the Editor:

“…We applaud Fazio and Carlomagno for raising awareness to the potential harm associated with ICD implantation 1 . Based on their review and our clinical experience with the three described cases, we strongly support their call for a prospective study to test what patient characteristics or implant methods may be implicated in the occasionally devastating condition of post‐ICD RHF.…”

“…We read with great interest the recent “Viewpoint” article by Fazio and Carlomagno in which they raised awareness to the possible harmful effect of implantable cardioverter‐defibrillator (ICD) lead placement on tricuspid valve function, and to the possibility of worsening right heart failure (RHF) following ICD implant 1 . We would like to support their conclusions by presenting three recent cases where severe and progressive RHF was temporally related to the implantation of prophylactic ICD.…”

A Clinical Phenotype of Adverse Response to Biventricular Pacing: A Case Series

“…A previous case report described worsening of heart failure due to worsening of ventricular dyssynchrony in a patient with preexisting RBBB . A similar mechanism would be intuitively attractive, but other mechanisms may include worsening of tricuspid regurgitation, adverse effects of RV pacing, and series or parallel ventricular interaction . That the clinical deterioration in these patients is likely to be (at least in part) related to RV failure is supported by the acute detrimental effects of biventricular pacing on RV stroke work and echocardiographic deterioration in RV function.…”

“…8 A similar mechanism would be intuitively attractive, but other mechanisms may include worsening of tricuspid regurgitation, adverse effects of RV pacing, and series or parallel ventricular interaction. 9,10 That the clinical deterioration in these patients is likely to be (at least in part) related to RV failure is supported by the acute detrimental effects of biventricular pacing on RV stroke work and echocardiographic deterioration in RV function. Similarly, the development of RBBB in these cases is likely to be associated with pulmonary hypertension and adverse RV pressure loading, which is well recognized in the literature.…”

To the Editor:

“…I would like to offer three comments on Fazio and Carlomagno's thesis of hemodynamic deterioration as a result of right ventricular (RV) dysfunction following biventricular pacing 1 . First, RV function is a key determinant of functional capacity and prognosis in patients with heart failure 2 .…”