Managing CIED TLE For TTVR Focus of State-of-the-Art Review

A multidisciplinary care team (MDT) must balance the risks and benefits of transvenous lead extraction (TLE) vs. entrapping leads in patients with preexisting leads from cardiac implantable electronic device (CIED) being considered for orthotopic transcatheter tricuspid valve replacement (TTVR), which accounts for roughly 35% of the TTVR population, according to a JACC State-of-the-Art Review, published May 13.

Rebecca T. Hahn, MD, et al., review a consensus document stemming from a workshop held by the Heart Valve Collaboratory, including a description of the population most likely to have CIED lead-associated or lead-induced tricuspid regurgitation (TR), the risks of lead entrapment during TTVR in this population and the risks and benefits of TLE, as well as a management algorithm.

The authors discuss the two main concerns regarding CIED lead entrapment, subsequent device-related infection and lead failure, along with the three main issues related to TLE and TR, which are safety and potential hazards of TLE, incidence of worsening TR after TLE and incidence of TR reduction after TLE. In addition, they discuss considerations regarding CIED therapy after TV intervention, and highlight the gaps in knowledge to guide clinical practice because of the limited experience with TTVIs and the developing technologies for CIED therapies. The working group also suggests a "call to action" to address several of these gaps.

The management algorithm emphasizes the importance of the MDT that should include an electrophysiologist "because patients with severe, symptomatic TR may need management of CIEDs not only before and/or after TTVI, but also for rhythm management, which can be a management strategy to reduce TR severity."

"Importantly, transcatheter and surgical management of patients with severe, symptomatic TR continues to evolve," Hahn, et al. write, "and this consensus statement will require updating as more evidence for management outcomes becomes available."

Keywords: Tricuspid Valve, Tricuspid Valve Insufficiency, Patient Care Team

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