Congenital: Tricuspid Valve
Surgical management of transvenous lead-induced tricuspid regurgitation in adult and pediatric patients with congenital heart disease

https://doi.org/10.1016/j.jtcvs.2021.10.006Get rights and content

Abstract

Objective

The objective of this study was to evaluate outcomes of surgical management of lead-induced tricuspid regurgitation (TR) in patients with congenital heart disease.

Methods

We analyzed data of 54 consecutive patients who underwent tricuspid valve (TV) surgery from 1998 to 2015 for lead-induced TR. Primary end points, including mortality, TV reinterventions, and longitudinal TR measurements, were analyzed with the Kaplan–Meier method or with repeated measures proportional odds modeling.

Results

The median age of patients was 48.2 years (interquartile range, 37.3-59.0 years); 31 (57.4%) were female; 2 (3.7%) were children. Thirty patients (55.6%) underwent TV repair and 24 (44.4%) had replacement, and 52 underwent concomitant cardiac procedures. Thirty-day mortality was 1.9% (repair: 3.3%, replacement: 0.0%). Five-year survival was 80.4% overall and 79.7% and 81.4% for the repair and replacement groups, respectively. In response to surgery, TR improved in both groups (each P < .001) but more with replacement than repair (P < .001); longitudinal analysis showed that TR trends observed early on favoring replacement were sustained across follow-up (P < .001). The model-estimated risk of moderate or severe TR at 5-year follow-up, conditional on having severe preoperative TR, was 74.4% for the repair and 10.7% for the replacement group. Five-year cumulative risk of TV reintervention was comparable for valve repair and replacement.

Conclusions

Despite the need for concomitant cardiac procedures in most of the patients, early mortality was low after TV surgery. Survival and rate of TV reintervention were comparable for the repair and replacement groups. However, TV repair was associated with progressive TR during intermediate follow-up, especially in patients with severe preoperative TR.

Section snippets

Study Design

The study included patients with CHD who underwent elective TV surgery for lead-induced TR between January 1, 1998, and December 31, 2015, at Mayo Clinic, Rochester, Minnesota. Lead-induced TR was determined by surgical inspection and/or echocardiography. The study was approved by the Mayo Foundation Institutional Review Board (16-006244; Aug 18, 2016). A waiver of informed consent was granted. Data from patients who provided general research authorization were included in the study.

Data Collection and Study Groups

Patients

Patients

Median age of the 54 patients was 48.2 years (IQR, 37.3-59.0 years); 31 were female (57.4%). This subset represented 3.9% of 1400 patients with CHD who underwent TV surgery for TR during the study period. The temporal distribution of included patients is shown in Figure E1. Lead-induced TR was documented in the surgeon's description for 40 patients (74.1%), identified on intraoperative TEE for 28 patients (51.9%), and preoperative echocardiography for 26 patients (48.2%).

Thirty patients (55.6%)

Discussion

Cardiac rhythm devices including PMs, ICDs, and CRTDs are used with increasing frequency to prevent and manage late arrhythmic complications in patients with repaired CHD. When the anatomy and patient size permit, a transvenous cardiac device is generally preferred. However, lead-induced TR remains a major concern, and there is little information concerning management of device-related TR in patients with CHD. Although the Micra TPS leadless PM was approved by the US Food and Drug

Conclusions

Patients with CHD who had lead-induced TR were young. Despite the need for concomitant cardiac procedures in most patients, early mortality was low (1.9%) after TV repair (3.3%) and replacement (0.0%). Overall survival and cumulative risk of TV reintervention at 5 years were both acceptable (80.4% and 2.4%, respectively). TV repair was associated with progressive TR during intermediate follow-up, particularly in patients who had preoperative severe TR. In the repair group, moderate or severe TR

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  • This study was supported by Dr Dearani’s Sheikh Zayed Professorship of Cardiovascular Diseases Honoring George M. Gura, MD.

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