Lead dependent tricuspid dysfunction: Analysis of the mechanism and management in patients referred for transvenous lead extraction

Abstract

Background: Lead-dependent tricuspid dysfunction (LDTD) is one of important complications
in patients with cardiac implantable electronic devices. However, this phenomenon is
probably underestimated because of an improper interpretation of its clinical symptoms. The
aim of this study was to identify LDTD mechanisms and management in patients referred for
transvenous lead extraction (TLE) due to lead-dependent complications.

Methods: Data of 940 patients undergoing TLE in a single center from 2009 to 2011 were
assessed and 24 patients with LDTD were identifi ed. The general indications for TLE, pacing
system types and lead dwell time in both study groups were comparatively analyzed. The
radiological and clinical effi cacy of TLE procedure was also assessed in both groups with precision
estimation of clinical status patients with LDTD (before and after TLE). Additionally,
mechanisms, concomitant lead-dependent complications and degree (severity) of LDTD before
and after the procedure were evaluated. Telephone follow-up of LDTD patients was performed
at the mean time 1.5 years after TLE/replacement procedure.

Results: The main indications for TLE in both groups were similar (apart from isolated
LDTD in 45.83% patients from group I). Patients with LDTD had more complex pacing systems
with more leads (2.04 in the LDTD group vs. 1.69 in the control group; p = 0.04). There
were more unnecessary loops of lead in LDTD patients than in the control group (41.7% vs.
5.24%; p = 0.001). There were no signifi cant differences in average time from implantation
to extraction and the number of preceding procedures. Signifi cant tricuspid regurgitation
(TR-grade III–IV) was found in 96% of LDTD patients, whereas stenosis with regurgitation
in 4%. The 10% frequency of severe TR (not lead dependent) in the control group patients was
observed. The main mechanism of LDTD was abnormal leafl et coaptation caused by: loop of
the lead (42%), septal leafl et pulled toward the interventricular septum (37%) or too intensive
lead impingement of the leafl ets (21%). LDTD patients were treated with TLE and reimplantation
of the lead to the right ventricle (87.5%) or to the cardiac vein (4.2%), or surgery procedure with epicardial lead placement following ineffective TLE (8.3%). The radiological and clinical
effi cacy of TLE procedure was very high and comparable between the groups I and II (91.7%
vs. 94.2%; p = 0.6 and 100% vs. 98.4%; p = 0.46, respectively). Repeated echocardiography
showed reduced severity of tricuspid valve dysfunction in 62.5% of LDTD patients. The follow-
-up interview confi rmed clinical improvement in 75% of patients (further improvement after
cardiosurgery in 2 patients was observed).

Conclusions: LDTD is a diagnostic and therapeutic challenge. The main reason for LDTD
was abnormal leafl et coaptation caused by lead loop presence, or propping, or impingement
the leafl ets by the lead. Probably, TLE with lead reimplantation is a safe and effective option
in LDTD management. An alternative option is TLE with omitted tricuspid valve reimplantation.
Cardiac surgery with epicardial lead placement should be reserved for patients with
ineffective previous procedures.