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Bioprosthetic Tricuspid Valve Regurgitation Associated With Pacemaker or Defibrillator Lead Implantation
Study Questions:
Does the presence of a permanent transvenous device lead affect bioprosthetic tricuspid valve function?
Methods:
A retrospective review was conducted of 58 patients who underwent bioprosthetic tricuspid valve implantation and subsequently required endocardial pacemaker (n = 52) or defibrillator (n = 6) lead implantation across the bioprosthetic valve. Patient and prosthesis characteristics, lead type, and clinical events were collected. The incidence and severity of prosthetic tricuspid regurgitation (TR), determined by Doppler echocardiography, was compared with 265 consecutive patients who underwent bioprosthetic tricuspid valve implantation without undergoing subsequent transvalvular device lead implantation.
Results:
Over a mean follow-up of 25 months, significant (moderate or greater) prosthetic TR developed in five patients (9%) with a transvalvular lead compared with 12 patients (5%) in the control group (p = 0.20). Kaplan-Meier analysis revealed no significant difference in the incidence of TR in bioprosthetic tricuspid valve patients with and without transvalvular leads (p = 0.45). Significant prosthetic TR occurred more commonly 2 years or later after lead or valve implantation (four of five patients [80%] with a transvalvular lead and 10 of 12 patients [83%] without a transvalvular lead).
Conclusions:
Transvalvular device lead implantation in patients with a bioprosthetic tricuspid valve was not associated with an increased incidence of significant prosthetic TR. Based on these data, the authors concluded that transvalvular lead implantation appears to be an acceptable approach for patients with a bioprosthetic tricuspid valve who require permanent pacemaker or defibrillator placement.
Perspective:
Previously published studies have suggested that permanent transvenous pacemaker or implantable cardioverter defibrillator (ICD) leads might be associated with the development of native tricuspid valve regurgitation, with a surgical study citing mechanisms of leaflet perforation, entanglement of subvalvular apparatus, mechanical inhibition of normal leaflet closing, or leaflet adhesion to the lead. However, clinical experience might suggest that most patients with a right-sided lead do not develop clinically significant native TR. This retrospective study of 58 patients with a bioprosthetic tricuspid valve followed for 25 months after pacemaker or ICD placement detected no statistically significant increase in the prevalence of moderate or severe TR compared to 265 patients with a bioprosthetic tricuspid valve and no right-sided lead. The absence of difference between groups could have been due to a true absence of risk, or due to a study limited in terms of both patient numbers and follow-up duration. Whether risk is absent or low, it seems reasonable to use transvenous leads when indicated among patients after bioprosthetic tricuspid valve replacement.
Keywords: Defibrillators, Kaplan-Meier Estimate, Tricuspid Valve Insufficiency, Pacemaker, Artificial, Echocardiography
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