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

Technique

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.

Conclusions

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