Severe tricuspid regurgitation due to interactions with right ventricular permanent pacemaker or defibrillator leads

Leadless pacemaker implantation following tricuspid interventions: multicenter collaboration of feasibility and safety

BACKGROUND

Permanent pacing is often required following valve intervention (either surgical or percutaneous); however, tricuspid interventions pose specific challenges to conventional pacing. Therefore, leadless pacemaker (LP) implantation may be the preferred strategy when permanent pacing is required after tricuspid valve intervention.

PURPOSE

To report periprocedural outcomes and follow-up of patients undergoing implantation of a LP system following tricuspid valve interventions.

METHODS

Patients with previous tricuspid valve intervention at the time of attempted implantation of a LP (MicraTM, Medtronic, Minneapolis, MN, USA) were included.

RESULTS

Between 2019 and 2022, 40 patients underwent LP implantations following tricuspid interventions in 5 large tertiary centers. The mean age was 68.9 ± 13.7 years, and 48% patients were male. The indication for pacing was as following: AVB in 27 (68%) patients, AF with slow ventricular response in 10 (25%) patients, and refractory rapid atrial fibrillation (AF) referred to AV junction ablation in 3 (7%) patients. Most of the patients received Micra VR (78%). The procedure was successful in all patients. The mean procedural time is 58 ± 32 min, and the median fluoroscopy time is 7.5 min. Electrical parameters were within normal range (threshold: 1.35 ± 1.2 V@0.24 ms, impedance: 772 ± 245 Ohm, R-wave: 6.9 ± 5.4 mV). No acute complications were observed. During a mean follow-up of 10 months, electrical parameters remained stable, and 4 deaths were occurred (not related to the procedure).

CONCLUSION

A LP is a safe and efficient option following tricuspid valve interventions.

Evolution of ventricular and valve function in patients with right ventricular pacing - A randomized controlled trial comparing leadless and conventional pacing

BACKGROUND

Leadless pacemakers (PMs) were recently introduced to overcome lead-related complications. They showed high safety and efficacy profiles. Prospective studies assessing long-term safety on cardiac structures are still missing.

OBJECTIVE

The purpose of this study was to compare the mechanical impact of Micra with conventional PM on heart function.

METHODS

We conducted a non-inferiority trial in patients with an indication for single chamber ventricular pacing. Patients were 1:1 randomized to undergo implantation of either Micra or conventional monochamber ventricular pacemaker (PM). Patients underwent echocardiography at baseline, 6 and 12 months after implantation. Analysis included left ventricular ejection fraction (LVEF), global longitudinal strain (GLS) and valve function. N-terminal-pro hormone B-type natriuretic peptide (NT-pro-BNP) levels were measured at baseline and 12 months.

RESULTS

Fifty-one patients (27 in Micra group and 24 in conventional group) were included. Baseline characteristics were similar for both groups. At 12 months, (1) the left ventricular function as assessed by LVEF and GLS worsened similarly in both groups (∆LVEF -10 ± 7.3% and ∆GLS +5.7 ± 6.4 in Micra group vs. -13.4 ± 9.9% and +5.2 ± 3.2 in conventional group) (p = 0.218 and 0.778, respectively), (2) the severity of tricuspid valve regurgitation was significantly lower with Micra than conventional pacing (p = 0.009) and (3) median NT-pro-BNP was lower in Micra group (970 pg/dL in Micra group versus 1394 pg/dL in conventional group, p = 0.041).

CONCLUSION

Micra is non inferior to conventional PMs concerning the evolution of left ventricular function at 12-month follow-up. Our data suggest that Micra has a comparable mechanical impact on the ventricular systolic function but resulted in less valvular dysfunction.

Worsening tricuspid regurgitation associated with permanent pacemaker and implantable cardioverter-defibrillator implantation: A systematic review and meta-analysis of more than 66,000 subjects

BACKGROUND

Worsening tricuspid regurgitation (TR) after either permanent pacemaker (PPM) or implantable cardioverter-defibrillator (ICD) implantation is an emerging clinical challenge. Early recognition of this entity is essential in guiding treatment.

OBJECTIVE

This meta-analysis was designed to identify the overall incidence and patient-specific predictors of TR post-device implantation.

METHODS

We searched electronic databases from inception to January 2023 for published studies that reported the incidence of TR worsening post-device implantation. The log odds ratio (OR) was used to summarize group differences.

RESULTS

Our analysis included 29 studies with 66,590 participants. Patients who underwent device implantation (n = 1008) were significantly more likely to develop worsening TR than controls who did not undergo device implantation (n = 58,605) (OR 3.18; P < .01). In a total of 7777 patients, the pooled incidence of at least 1-grade worsening of TR post-device implantation was 24%. Worsening TR post-device implantation significantly increases mortality (hazard ratio 1.42; P = .02). Larger right atrial area (OR 1.11; P < .01) is significantly associated with an increased risk of worsening TR post-device implantation, while male patients are less likely to develop this complication than female patients (OR 0.74; P < .01). Importantly, there is no statistically significant difference between the type of implanted device (ICD vs PPM) and post-device implantation TR. Further, right ventricular dysfunction, pulmonary artery pressure, baseline mitral regurgitation, left ventricular ejection fraction, baseline atrial fibrillation, and age have no association with worsening TR post-device implantation.

CONCLUSION

A substantial number of patients undergoing PPM or ICD implantation are at an increased risk of worsening TR. Importantly, in this largest review to date incorporating more than 66,000 subjects, worsening TR significantly increases mortality by greater than 140%, accordingly deserving more recognition and clinical attention in the current era.

Tricuspid Regurgitation (TR) after Implantation of a Cardiac Implantable Electronic Device (CIED)-One-Year Observation of Patients with or without Left Ventricular Dysfunction

The frequency of tricuspid regurgitation (TR) progression after cardiac implantable electronic devices (CIEDs) implantation varies from 7.2% to 44.7%. TR is associated with increased mortality and hospitalizations due to heart failure (HF) decompensation. The aim of this study was to assess the rate of early TR progression after CIED implantation and the frequency of HF decompensation and mortality. The 101 patients, who received a CIED between March 2020 and October 2021, before the procedure were divided into two groups-one with left ventricle ejection fraction (LVEF) ≥ 40% (n = 60) and one with LVEF < 40% (n = 41). Lead-related tricuspid regurgitation (LRTR) was defined as an increase of TR by at least one grade. The follow-up period was similar between both groups and was on average 13 (12-16) months. In the whole study group, TR progression by one grade was 34.6% and by two or more grades 15.8%. The significant changes in the dynamic of TR degree were as follows before and after implantation: none/trivial TR in group 1 (61.7% vs. 28.3%, p = 0.01) and severe/massive TR in group 2 (0.0% vs. 14.6%, p = 0.03). The groups did not differ from each other in terms of survival from decompensation of HF (18.3% vs. 36.6%, p = 0.70) and survival from death (1.7% vs. 4.9%, p = 0.16). At the one-year follow-up, the baseline LVEF did not affect the survival rate from death or HF decompensation among patients with a progression of TR after CIED implantation. In this study, a progression by one grade was more common in group 1, but the occurrence of severe/massive TR after implantation was more specific for group 2.

Identification of Pacemaker Lead Position Using Fluoroscopy to Avoid Significant Tricuspid Regurgitation

Permanent pacemaker implantation improves survival but can cause tricuspid valve dysfunction in the form of tricuspid regurgitation (TR). The dominant mechanism of pacemaker-mediated TR is lead impingement. This study evaluated the association between the location of the pacemaker leads crossing the tricuspid valve and the incidence of worsening TR and lead impingement using fluoroscopy. Lead positions were evaluated using perpendicular right anterior oblique (RAO) and parallel left anterior oblique (LAO) fluoroscopic angulation views of the tricuspid annulus. A two-dimensional transthoracic echocardiogram (TTE) was performed to evaluate the maximum TR jet area-to-right atrium ratio and define regurgitation severity. A three-dimensional TTE was performed to evaluate lead impingement. A worsening of TR was observed in 23 of 82 subjects. Most leads had an inferior position in the RAO view and a septal position in the LAO view. The mid position in the RAO view and septal position in the LAO view were risk factors for lead impingement. Mid and septal positions were associated with higher risks of significant TR and lead impingement. Lead impingement was associated with a high risk of significant TR. Pacemaker-mediated TR remains a significant problem after lead implantation.

Acute heart failure and valvular heart disease: A scientific statement of the Heart Failure Association, the Association for Acute CardioVascular Care and the European Association of Percutaneous Cardiovascular Interventions of the European Society of Cardiology

Acute heart failure (AHF) represents a broad spectrum of disease states, resulting from the interaction between an acute precipitant and a patient's underlying cardiac substrate and comorbidities. Valvular heart disease (VHD) is frequently associated with AHF. AHF may result from several precipitants that add an acute haemodynamic stress superimposed on a chronic valvular lesion or may occur as a consequence of a new significant valvular lesion. Regardless of the mechanism, clinical presentation may vary from acute decompensated heart failure to cardiogenic shock. Assessing the severity of VHD as well as the correlation between VHD severity and symptoms may be difficult in patients with AHF because of the rapid variation in loading conditions, concomitant destabilization of the associated comorbidities and the presence of combined valvular lesions. Evidence-based interventions targeting VHD in settings of AHF have yet to be identified, as patients with severe VHD are often excluded from randomized trials in AHF, so results from these trials do not generalize to those with VHD. Furthermore, there are not rigorously conducted randomized controlled trials in the setting of VHD and AHF, most of the data coming from observational studies. Thus, distinct to chronic settings, current guidelines are very elusive when patients with severe VHD present with AHF, and a clear-cut strategy could not be yet defined. Given the paucity of evidence in this subset of AHF patients, the aim of this scientific statement is to describe the epidemiology, pathophysiology, and overall treatment approach for patients with VHD who present with AHF.

Effects of Cardiac Contractility Modulation Electrodes on Tricuspid Regurgitation in Patients with Heart Failure with Reduced Ejection Fraction: A Pilot Study

BACKGROUND

Cardiac contractility modulation (CCM) is an innovative therapy for heart failure with reduced ejection fraction delivered by a cardiac implantable device (Optimizer Smart^®). One of the most prominent periprocedural complications common to all cardiac implantable devices (CIDs) is tricuspid regurgitation (TR) due to the placement of the right ventricular endocardial leads. To date, no published studies have assessed the changes in the TR degree in patients with heart failure with reduced ejection fraction (HFrEF) who received an implantable cardioverter-defibrillator (ICD) after the implantation of cardiac contractility modulation therapy devices.

OBJECTIVE

This study aimed to evaluate the effect of the implantation of the trans-tricuspid leads required to deliver CCM therapy on the severity of TR in patients with HFrEF who previously underwent ICD implantation.

METHODS

We enrolled 30 HFrEF patients who underwent CCM therapy between November 2020 and October 2021. For all the patients, echocardiographic evaluations of TR were performed according to current guidelines 24 h before and six months after the Optimizer Smart^® implant was applied.

RESULTS

At the 6-month follow-up, the grade of TR remained unchanged compared to the preimplant grade. The value of the vena contracta (VC) of TR was 0.40 ± 0.19 cm in the preimplant period and 0.45 ± 0.21 cm at the 6-month follow-up (p = 0.33). Similarly, the TR proximal isovelocity surface area (PISA) radius value was unchanged at follow-up (0.54 ± 0.22 cm vs. 0.62 ± 0.20 cm; p = 0.18). No statistically significant difference existed between the preimplant VC and PISA radius values, irrespective of the device type.

CONCLUSIONS

The implantation of right ventricular electrodes for the delivery of CCM therapy did not worsen tricuspid regurgitation in patients with HFrEF and ICD.

Impact of His bundle pacing on right ventricular performance in patients undergoing permanent pacemaker implantation

BACKGROUND

His-Bundle pacing (HBP) is an emerging technique for physiological pacing. However, its effects on right ventricle (RV) performance are still unknown.

METHODS

We enrolled consecutive patients with an indication for pacemaker (PM) implantation to compare HBP versus RV pacing (RVP) effects on RV performance. Patients were evaluated before implantation and after 6 months by a transthoracic echocardiogram.

RESULTS

A total of 84 patients (age 75.1±7.9 years, 64% male) were enrolled, 42 patients (50%) underwent successful HBP, and 42 patients (50%) apical RVP. At follow up, we found a significant improvement in RV-FAC (Fractional Area Change)% [baseline: HBP 34 IQR (31-37) vs. RVP 33 IQR (29.7-37.2),p = .602; 6-months: HBP 37 IQR (33-39) vs. RVP 30 IQR (27.7-35), p < .0001] and RV-GLS (Global Longitudinal Strain)% [baseline: HBP -18 IQR (-20.2 to -15) vs. RVP -16 IQR (-18.7 to -14), p = .150; 6-months: HBP -20 IQR(-23 to -17) vs. RVP -13.5 IQR (-16 to -11), p < .0001] with HBP whereas RVP was associated with a significant decline in both parameters. RVP was also associated with a significant worsening of tricuspid annular plane systolic excursion (TAPSE) (p < .0001) and S wave velocity (p < .0001) at follow up. Conversely from RVP, HBP significantly improved pulmonary artery systolic pressure (PASP) [baseline: HBP 38 IQR (32-42) mmHg vs. RVP 34 IQR (31.5-37) mmHg,p = .060; 6-months: HBP 32 IQR (26-38) mmHg vs. RVP 39 IQR (36-41) mmHg, p < .0001] and tricuspid regurgitation (p = .005) irrespectively from lead position above or below the tricuspid valve.

CONCLUSIONS

In patients undergoing PM implantation, HBP ensues a beneficial and protective impact on RV performance compared with RVP.

Echocardiographic findings in patients with cardiac implantable electronic devices-analysis of factors predisposing to lead-associated changes

BACKGROUND

The constant interaction between intracardiac leads and the heart and veins results in excessive accumulation of fibrous connective tissue around the leads. The extent of this pathological phenomenon, which is visible on transesophageal echocardiography (TEE), and predisposing factors are not well defined.

METHODS

We examined 936 transesophageal echocardiograms prior to transvenous lead extraction (TLE) performed at a high-volume centre between 2015 and 2019.

RESULTS

The most important echocardiographic findings were fibrous binding sites between leads and cardiovascular structures, lead-to-lead adhesions, excessive lead loops, lead-dependent tricuspid dysfunction (LDTD), asymptomatic masses on endocardial leads (AMEL) and vegetations. Fibrotic reaction within the walls of the heart and veins correlated with the presence of lead loops (OR = 1.771; p < .01) and lead dwell time (OR = 1.111; p < .001). Women were more likely to have excessive lead loops (OR = 1.639; p < .01), and the occurrence of loops increase with the number of implanted leads (OR = 2.557; p < .001). Heart failure (OR = 4.016; p < .001), lead looping (OR = 2.603; p < .01) and longer cumulative lead dwell time (OR = 1.017; p < .05) increased the likelihood of LDTD. A variety of AMEL were identified in this study, most commonly in patients with older leads (OR = 1.043; p < .001).

CONCLUSIONS

Lead dwell time is the main factor predisposing to the occurrence of most lead-associated phenomena visualized by TEE in patients with cardiac implantable electronic devices (CIED). Excessive looping of the lead is an important cause of fibrous binding sites and LDTD. AMEL are frequently detected in CIED patients, and their various forms concurrent with vegetations could represent an evolutionary stage of lead-associated masses.

Imaging and Patient Selection for Transcatheter Tricuspid Valve Interventions

With the emergence of transcatheter solutions for the treatment of tricuspid regurgitation (TR) increased attention has been directed to the once neglected tricuspid valve (TV) complex. Recent studies have highlighted new aspects of valve anatomy and TR etiology. The assessment of valve morphology along with quantification of regurgitation severity and RV function pose several challenges to cardiac imagers guiding transcatheter valve procedures. This review article aims to give an overview over the role of modern imaging modalities during assessment and treatment of the TV.

Multi-Modality Imaging in the Evaluation and Treatment of Tricuspid Regurgitation

PURPOSE OF REVIEW

The goal of this review is to cover the epidemiology of tricuspid regurgitation (TR), anatomy of the tricuspid valve (TV), and the mechanisms and modern treatment of TR. The focus will be on the role of echocardiography, cardiac CT, and MRI to determine the mechanism, severity, and management strategies of TR.

RECENT FINDINGS

The evaluation and management of TR is a rapidly growing field with significant advances in both imaging and interventions. Important advances have been made to understand TV anatomy and physiology in 3D echo, CT, and MRI. Additional understanding of the abnormal outcomes in both primary TR and secondary TR have been appreciated. Multiple transcatheter devices have reached the stage of early trials in high surgical risk cohorts with favorable initial findings. TR is a significant cardiovascular problem and vastly undertreated in the present era. There has been tremendous growth in knowledge of mechanisms of TR, its prognostic implications, timing of intervention, and development of novel treatment strategies. Multimodality imaging plays a key role in evaluation and treatment of this condition.