Endocardial lead–induced tricuspid regurgitation has not been well recognized, either clinically or echocardiographically, and yet it is likely a preventable iatrogenic disease. In severe cases, it can lead to right ventricular failure and require tricuspid valve surgery. This complication will become increasingly important, because the numbers of permanent pacemakers and implantable cardioverter-defibrillators are expected to increase because of the aging population and the expanding capabilities of these devices. Published studies are largely retrospective, and serial studies to assess the time course of the development of tricuspid regurgitation are lacking. The mechanisms and severity of tricuspid regurgitation may not be well evaluated by two-dimensional echocardiography. Real-time three-dimensional echocardiography appears to be a promising technique to evaluate the mechanism of tricuspid regurgitation and may allow the early detection of patients who will develop severe lead-induced tricuspid regurgitation. A better understanding of the mechanism of lead-induced tricuspid regurgitation will be essential to the development of preventive strategies, which can then be tested in future clinical trials.
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Prevalence of Lead-Related Tricuspid Regurgitation
Permanent cardiac pacing was introduced >50 years ago, and despite many technological advances, the transvenous implantation of endocardial leads remains the cornerstone of the procedure. The endocardial lead may damage or interfere with tricuspid valve (TV) function. Newly developed TR after the implantation of endocardial leads for PPM was described more than three decades ago ( Figure 1 ), and it has been noted that the TR murmur that is indicative of TV dysfunction may resolve with repositioning of the pacemaker lead. Detection of TR by clinical examination alone may be problematic, because clinical findings of TR are subtle and TR murmur may be difficult to detect. Two-dimensional (2D) echocardiography may underestimate TR severity because of suboptimal imaging of the regurgitant jet resulting from the acoustic shadowing artifact of the pacemaker lead. A goal-oriented echocardiographic study is essential in the detection of this complication.
Beyond the case reports, conflicting data have been reported regarding the frequency of TR related to endocardial lead implantation. The pertinent published case series are summarized in Table 1 . There are limitations with these studies. Many of the studies were retrospective, included few patients, had no predefined follow-up, and failed to assess the functional significance of TR. In the older studies, TR jet area or the ratio of jet area to right atrial area was commonly used to grade TR severity. Recent studies, such as those by Vaturi et al. and Alizadeh et al. , included vena contracta width in addition to jet area. The grading scheme has not been uniform, with some studies using a four-grade scheme (mild, moderate, moderate-severe, and severe) and others a three-grade scheme (mild, moderate, and severe). Kim et al. used a six-grade scheme to provide a more refined assessment of TR severity, but the interobserver and intraobserver variability of the grading scheme was not reported. None of the studies had independent determinations of TR severity besides echocardiographic measures. In view of the differences among the studies, it is not surprising that there is a large range in TR frequency (7.2%–39%) among them. The studies by Kim et al. and Klutstein et al. had larger sample sizes and included for comparison echocardiographic assessments for TR before lead implantation. Kim et al. reported increases of one or more grades in TR in 24.2% of patients, while Klutstein et al. showed increases of two or more grades in 18.3% of patients. In a recent study of 115 patients, Alizadeh et al. reported moderate TR in 10 patients before and 36 patients after PPM.
| Study | Sample size | Study design | Follow-up | Findings | Assessment of TR severity |
|---|---|---|---|---|---|
| Sakai et al. (1987) | 18 patients, 26 autopsies | Prospective | NA | 5 patients (28%) had TR; 11 autopsies (42%) showed interference of valve motion by pacer leads | Pulsed Doppler and contrast echocardiography for diagnosis of TR; TR severity was not graded |
| Paniagua et al. (1998) | 374 | Retrospective case control | NA | Patients were identified from the echocardiography database; more than moderate TR in 7.2% in cases vs 1.7% in controls ( P < .0001) | TR graded 1 to 4 (mild to severe) on the basis of jet length and jet area |
| Leibowitz et al. (2000) | 35 | Prospective | 1.2 ± 0.7 d | More than moderate TR in 10 patients before and 7 patients after PPM implantation ( P = NS) | TR graded 0 to 3 (none to severe) on the basis of jet area and jet area/RA area ratio |
| Lin et al. (2005) | 41 | Retrospective | 77 mo (range, 2–228 mo) | 41 patients referred for TV surgery because of severe TR due to endocardial lead; limited preimplantation data | NA |
| Kucukarslan et al. (2006) | 61 | Prospective | 6 ± 3 mo | More than moderate TR in 9 patients before and 12 patients after PPM implantation ( P = NS); timing of first postprocedural echocardiographic study was not specified | TR graded 0 to 3 (none to severe) on the basis of jet area |
| Seo et al. (2008) | 87 | Retrospective | 36 mo | 3D echocardiography was used to assess TV; more than moderate TR in 32 patients (39%); interference of TV leaflet motion in 7 of 12 patients with severe TR | TR graded 1 to 3 (mild to severe) on the basis of jet area/RA area ratio |
| Kim et al. (2008) | 248 | Retrospective | 93 d (range, 23–199) | Preprocedural and postprocedural echocardiography showed >1-grade increases in TR in 24.2% of patients, with moderate-severe and severe TR in 4% of patients | TR graded 0 to 3 (none to severe) on the basis of jet area and other measures according to guidelines |
| Klutstein et al. (2009) | 410 | Retrospective | 75 d (range, 1–4,367 d) | Preprocedural and postprocedural echocardiography showed that 75 patients (18.3%) had >2-grade increases in TR | TR graded 1 to 4 (mild to severe) on the basis of a visual scale |
| Vaturi et al. (2010) | 23 | Prospective | 48.6 ± 32.7 mo | In 23 patients who were not pacemaker dependent, acute RV pacing showed more than moderate TR in 18 patients vs 9 patients during normal conduction | TR graded 1 to 3 (mild to severe) on the basis of jet area and vena contracta width |
| Alizadeh et al. (2011) | 115 | Prospective | 4.1 ± 0.8 y | More than moderate TR was present in 10 patients before and 36 patients after PPM implantation ( P < .001) | TR graded 1 to 3 (mild to severe) on the basis of jet area and vena contracta width |
Prevalence of Lead-Related Tricuspid Regurgitation
Permanent cardiac pacing was introduced >50 years ago, and despite many technological advances, the transvenous implantation of endocardial leads remains the cornerstone of the procedure. The endocardial lead may damage or interfere with tricuspid valve (TV) function. Newly developed TR after the implantation of endocardial leads for PPM was described more than three decades ago ( Figure 1 ), and it has been noted that the TR murmur that is indicative of TV dysfunction may resolve with repositioning of the pacemaker lead. Detection of TR by clinical examination alone may be problematic, because clinical findings of TR are subtle and TR murmur may be difficult to detect. Two-dimensional (2D) echocardiography may underestimate TR severity because of suboptimal imaging of the regurgitant jet resulting from the acoustic shadowing artifact of the pacemaker lead. A goal-oriented echocardiographic study is essential in the detection of this complication.
Beyond the case reports, conflicting data have been reported regarding the frequency of TR related to endocardial lead implantation. The pertinent published case series are summarized in Table 1 . There are limitations with these studies. Many of the studies were retrospective, included few patients, had no predefined follow-up, and failed to assess the functional significance of TR. In the older studies, TR jet area or the ratio of jet area to right atrial area was commonly used to grade TR severity. Recent studies, such as those by Vaturi et al. and Alizadeh et al. , included vena contracta width in addition to jet area. The grading scheme has not been uniform, with some studies using a four-grade scheme (mild, moderate, moderate-severe, and severe) and others a three-grade scheme (mild, moderate, and severe). Kim et al. used a six-grade scheme to provide a more refined assessment of TR severity, but the interobserver and intraobserver variability of the grading scheme was not reported. None of the studies had independent determinations of TR severity besides echocardiographic measures. In view of the differences among the studies, it is not surprising that there is a large range in TR frequency (7.2%–39%) among them. The studies by Kim et al. and Klutstein et al. had larger sample sizes and included for comparison echocardiographic assessments for TR before lead implantation. Kim et al. reported increases of one or more grades in TR in 24.2% of patients, while Klutstein et al. showed increases of two or more grades in 18.3% of patients. In a recent study of 115 patients, Alizadeh et al. reported moderate TR in 10 patients before and 36 patients after PPM.
| Study | Sample size | Study design | Follow-up | Findings | Assessment of TR severity |
|---|---|---|---|---|---|
| Sakai et al. (1987) | 18 patients, 26 autopsies | Prospective | NA | 5 patients (28%) had TR; 11 autopsies (42%) showed interference of valve motion by pacer leads | Pulsed Doppler and contrast echocardiography for diagnosis of TR; TR severity was not graded |
| Paniagua et al. (1998) | 374 | Retrospective case control | NA | Patients were identified from the echocardiography database; more than moderate TR in 7.2% in cases vs 1.7% in controls ( P < .0001) | TR graded 1 to 4 (mild to severe) on the basis of jet length and jet area |
| Leibowitz et al. (2000) | 35 | Prospective | 1.2 ± 0.7 d | More than moderate TR in 10 patients before and 7 patients after PPM implantation ( P = NS) | TR graded 0 to 3 (none to severe) on the basis of jet area and jet area/RA area ratio |
| Lin et al. (2005) | 41 | Retrospective | 77 mo (range, 2–228 mo) | 41 patients referred for TV surgery because of severe TR due to endocardial lead; limited preimplantation data | NA |
| Kucukarslan et al. (2006) | 61 | Prospective | 6 ± 3 mo | More than moderate TR in 9 patients before and 12 patients after PPM implantation ( P = NS); timing of first postprocedural echocardiographic study was not specified | TR graded 0 to 3 (none to severe) on the basis of jet area |
| Seo et al. (2008) | 87 | Retrospective | 36 mo | 3D echocardiography was used to assess TV; more than moderate TR in 32 patients (39%); interference of TV leaflet motion in 7 of 12 patients with severe TR | TR graded 1 to 3 (mild to severe) on the basis of jet area/RA area ratio |
| Kim et al. (2008) | 248 | Retrospective | 93 d (range, 23–199) | Preprocedural and postprocedural echocardiography showed >1-grade increases in TR in 24.2% of patients, with moderate-severe and severe TR in 4% of patients | TR graded 0 to 3 (none to severe) on the basis of jet area and other measures according to guidelines |
| Klutstein et al. (2009) | 410 | Retrospective | 75 d (range, 1–4,367 d) | Preprocedural and postprocedural echocardiography showed that 75 patients (18.3%) had >2-grade increases in TR | TR graded 1 to 4 (mild to severe) on the basis of a visual scale |
| Vaturi et al. (2010) | 23 | Prospective | 48.6 ± 32.7 mo | In 23 patients who were not pacemaker dependent, acute RV pacing showed more than moderate TR in 18 patients vs 9 patients during normal conduction | TR graded 1 to 3 (mild to severe) on the basis of jet area and vena contracta width |
| Alizadeh et al. (2011) | 115 | Prospective | 4.1 ± 0.8 y | More than moderate TR was present in 10 patients before and 36 patients after PPM implantation ( P < .001) | TR graded 1 to 3 (mild to severe) on the basis of jet area and vena contracta width |
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