Severe Tricuspid Regurgitation Post Device Placement
abstract & commentary
By Michael H. Crawford, MD
Synopsis: Damage to the tricuspid valve caused by electrophysiologic device leads may be a cause of predominant right heart failure due to severe TR and may not be recognized on routine echocardiography.
Source: Lin G, et al. Severe Symptomatic Tricuspid Valve Regurgitation Due to Permanent Pacemaker or Implantable Cardioverter-Defibrillator Leads. J Am Coll Cardiol. 2005; 45:1672-1675.
Patients presenting with predominant right heart failure are often a diagnostic challenge. One frequently overlooked cause is severe tricuspid regurgitation due to electrophysiologic device lead implantation. This report from the Mayo Clinic in Rochester, MN, describes their experience with 41 such patients who required surgical intervention. They were derived from 1465 patients over 10 years who had surgery for severe tricuspid regurgitation (TR), of whom 156 had device leads across the valve, and 64 were determined at surgery to be due to the device lead. Among these 64, 23 were excluded because they had other potential causes of severe TR, such as endocarditis or congenital heart disease. The 41 patients had structurally normal tricuspid valves that appeared to have been damaged by the lead placement. Lead impingement or adherence to the valve was the most common finding (30 patients), followed by perforation (7) and entanglement (4). Perforation usually involved the septal leaflet. The average time from lead placement to surgery was 6 years (range, 2 months to 19 years). Half the patients had isolated tricuspid valve surgery. Repair was the preferred surgical approach when feasible, with suture fixation of the lead in either the posteroseptal or anteroposterior commissure. When valve replacement was preformed, the native valve was left intact and the lead was positioned external to the sewing ring of the prosthetic valve. No patients required additional surgery or lead revisions in 8 years of follow-up, and all improved symptomatically. Initial transthoracic echocardiography identified only 12% of the patients (5/41) with device lead induced TR, and severe TR was recognized in 63%. Transesophageal echo (TEE) in 38 patients detected lead induced TR in 45% and identified severe TR in all 38. Lin and colleagues concluded that damage to the tricuspid valve caused by electrophysiologic device leads may be a cause of predominant right heart failure due to severe TR and may not be recognized on routine echocardiography.
Although the incidence of this complication of right ventricular lead placement cannot be determined from this retrospective study of patients referred for surgery, Lin et al’s experience suggested that it is becoming more common because more devices are being placed and more leads are being put through the tricuspid valve. The major point of this article is that these surgically confirmed cases of severe TR due to electrophysiologic device lead problems were difficult to diagnose, yet this is a correctable cause of right heart failure and symptoms. Routine transthoracic echo detected only 12%, and even re-review of these studies only increased detection to 22%. TEE wasn’t much better at 45%, although TEE identified severe TR in all cases. The acoustic shadowing caused by the large leads obscures the TR jet and tricuspid valve anatomy. Therefore, you need to have a high index of suspicion when patients with devices present with right heart failure.
Since this is a retrospective series, specific issues with lead placement techniques, types of leads, and the number of leads placed could not be sorted out. Perhaps there are improvements in equipment and techniques that are being, or could be, implemented to reduce these problems.