Severe TR after CIED implantation: What to do

Raja Selvaraj
Cardiac Electrophysiologist
Professor of Cardiology

Tricuspid regurgitation after CIED implant

  • How important and how common ?
  • What is the cause ?
  • How to prevent ?
  • How to treat ?

How important and how common ?


Gould L, Reddy CVR, Yacob U, et al. Perforation of the Tricuspid Valve by a Transvenous Pacemaker. JAMA. 1974;230(1):86–87.

How important and how common?

  • Incidence varies from 7% to 45% depending on definition
  • TR begets TR
  • Associated with heart failure
  • Associated with increased mortality

TR after DDD pacemaker - 7.5%


Retrospective data from Cleveland Clinic - 10%


R. Al-Bawardy .. B. Wilkoff, et al. Tricuspid regurgitation and implantable devices. Pacing Clin Electrophysiol, 38 (2015), pp. 259-266

Increased mortality


Tricuspid Regurgitation and Mortality in Patients with Transvenous Permanent Pacemaker Leads Francesca N. Delling et al. Am J Cardiol. 2016 Mar 15; 117(6): 988–992.

Cause of TR

Mechanisms for lead related TR - Direct


Cause of TR

  • Direct TV injury
    • Perforation, avulsion, subvalvar apparatus damage
  • Interaction of lead with TV function
    • Impingement of leaflets, malcoaptation
  • RV remodeling due to pacing
  • Atrial fibrillation
  • TR begets TR

Echo diagnosis and caveats

  • Artifacts and signal attenuation from leads results in underestimation
  • Underestimation of eccentric TR due to Coanda effect
  • Assessment of hepatic vein flow can help
  • TEE more accurate
  • 3D echo to assess interaction between lead and valve (can see TV leaflets in cross section)

Prevention of TR

Which patients are at higher risk ?

  • Preexisting TR
  • LV dysfunction
  • RV dilatation
  • Atrial fibrillation

Avoid crossing TV when possible

  • Single chamber atrial pacemaker when ventricular pacing not necessary
  • ? His bundle pacing
  • CS lead for ventricular pacing in selected patients
  • Subcutaneous ICD


  • Active fixation leads instead of tined leads
  • Prolapsing to cross valve instead of direct crossing
  • Reduce number and thickness of leads

Leadless pacemaker

  • Can also be associated with TR
  • Unclear if incidence is less


Niek E.G. Beurskens et al. Impact of Leadless Pacemaker Therapy on Cardiac and Atrioventricular Valve Function Through 12 Months of Follow-Up. Circulation: Arrhythmia and Electrophysiology. 2019;12:e007124

3D echo guided implant


Mediratta A et al. 3D echocardiographic location of implantable device leads and mechanism of associated tricuspid regurgitation.JACC Cardiovasc Imaging. 2014; 7:337–347.

ICE guided implant

Management of TR

Management of significant TR

  • Volume optimization
    • Diuretics
    • With RV failure, cardiac output becomes preload dependent, limits diuretic use
  • Surgical Tricuspid valve repair / replacement
    • High mortality when isolated procedure (8-10%)
    • Especially with RV dysfunction
  • Percutaneous TV repair / replacement
    • Transcatheter clip repair - Triclip
    • Transcatheter valve replacement
  • Removing lead ?? (may not help)

Lead extraction ?

  • identify if "impinging lead"
  • May worsen TR
  • Risk of infection, death
  • Alternate pacing site / modality



James Chang et al. Tricuspid Valve Dysfunction Following Pacemaker or Cardioverter-Defibrillator Implantation. JACC 2017;69(18):2331-2341

Lead management - surgical TV repair


Transcatheter Tricuspid Valve Intervention in presence of CIED lead (Trivalve Registry)


Taramasso M et al. Outcomes of TTVI in Patients With Pacemaker or Defibrillator Leads: Data From the TriValve Registry. JACC Cardiovasc Interv. 2020 Mar 9;13(5):554-564.


  • CIED with RV lead associated with TR
  • May be due to direct lead impingement or indirect effects of pacing
  • Significant TR associated with heart failure and increased mortality
  • Distinguishing functional TR from lead related TR is critical
  • Best methods to prevent - unclear
  • When due to lead impingement, lead extraction may be required