Comparison of Outcomes in Patients With Heart Failure With Versus Without Lead-Induced Tricuspid Regurgitation After Cardiac Implantable Electronic Devices Implantations

doi:10.1016/j.amjcard.2020.05.039

The American Journal of Cardiology

Volume 130, 1 September 2020, Pages 85-93

https://doi.org/10.1016/j.amjcard.2020.05.039 Get rights and content

Highlights

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The etiology of worsened tricuspid regurgitation (TR) after cardiac implantable electronic devices implantations are classified into lead-induced and non-lead-induced TR.
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Three-dimensional echocardiography is helpful in diagnosis the etiology of worsened TR.
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Severities of non-lead-induced TR change depending on heart failure (HF) status by HF therapy.
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Lead-induced TR persists and causes refractory HF.
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Lead-induced TR is associated with a poorer prognosis than non-lead-induced TR.

Cardiac implantable electronic devices (CIED) implantations may cause lead-induced tricuspid regurgitation (LITR). Although patients with CIED have the risk of functional non-lead induced TR (Non-LITR). This study aimed to compare of clinical outcome between LITR and Non-LITR. The mechanism of TR was determined by 3-dimensional echocardiography. The primary end point was heart failure (HF) hospitalizations after CIED implantation. In patients with HF events, subsequent clinical outcomes after HF hospitalization were compared between no TR, LITR, and Non-LITR groups. In eligible 373 patients, 67 patients had HF hospitalization, of whom worsened TR was observed in 49 patients. In the remaining 307 patients, worsened TR was observed in only 10 patients (3.3%). Of the 49 patients with worsened TR, 18 patients (37%) had LITR. In 67 patients with HF hospitalization, 25 patients (37%) met rehospitalization. All severe LITR persisted after HF events. Meanwhile, severe Non-LITR improved to moderate or mild level. Cox proportional hazard model analyses revealed LITR was the independent risk factor of rehospitalization. Both LITR and Non-LITR were common at HF events after CIED implantations. However, LITR persisted and might contribute to a worse prognosis. In patients with TR after CIED implantations, 3-dimensional echocardiography should be performed to diagnose the LITR accurately, which may contribute to improving the clinical outcome.

Section snippets

Methods

Retrospectively, patients who were followed after CIED implantation from April 2011 to May 2017 at the University of Tsukuba hospital were enrolled. Patients who had moderate or more TR before CIED implantation were excluded. The hospital ethics committee approved the research protocol, and we provided information about this study online to allow patients to opt out (http://www.md.tsukuba.ac.jp/clinical-med/cardiology/research_group/research_group07.html).

First, we compared the baseline and

Results

Finally, 373 patients were studied among 379 patients with CIED implantation who were followed in the University of Tsukuba Hospital. The excluded 4 patients had moderate or severe TR at baseline, and the remaining 2 patients had inadequate echocardiographic images to determine the cause of worsened TR.

During a follow-up period of 6 to 24 months (median: 11 months), 67 (18%) patients hospitalized due to HF (Table 1). As compared with patients without HF events, the HF events group had

Discussion

The major findings are as follows: (1) worsened TR was observed in more than a half of patients with HF events after CIED implantation, of which LITR was less than half but had severe grade in all cases; (2) all patients with LITR were hospitalized due to HF, which was observed more in patients with CRT; (3) LITR was associated with poor clinical outcomes after discharge of HF events compared with Non-LITR, and was selected as the independent risk factor of rehospitalization; and (4) the course

The contribution of each author is as fllows

Yoshihiro Seo: Conceptualization, Writing-Original Draft, Writing - Review & Editing, Visualization. Hideki Nakajima: Development or design of methodology; creation of models, Writing-Original Draft, Visualization. Tomoko Ishizu, Noriko Iida, Kimi Sato, Masayoshi Yamamoto, Tomoko Machino-Ohtsuka: Investigation and Formal analysis. Akihiko Nogami, Nobuyuki Ohte and Masaki Ieda: Supervision and Project administration

Declaration of Interests

The authors declare that they have no known competing financial interests or personal relations that could have appeared to influence the work reported in this study.

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Cited by (8)

Incidence and Prognostic Implications of Cardiac-Implantable Device-Associated Tricuspid Regurgitation: A Meta-Analysis and Meta-Regression Analysis
2023, American Journal of Cardiology
New-onset or worsening tricuspid regurgitation (TR) is a well-established complication encountered after cardiac implantable electronic devices (CIEDs). However, there are limited and conflicting data on the true incidence and prognostic implications of this complication. This study aimed to bridge this current gap in the literature. Electronic databases MEDLINE, Embase, and Web of Science were systematically searched from inception to March 2023, for studies reporting the incidence and/or prognosis of CIED-associated new or worsening TR. Potentially eligible studies were screened and selected according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A random effect model meta-analysis and meta-regression analysis were performed, and I-squared statistic was used to assess heterogeneity. A total of 52 eligible studies, with 130,759 patients were included in the final quantitative analysis with a mean follow-up period of 25.5 months. The mean age across included studies was 69.35 years, and women constituted 46.6% of the study population. The mean left ventricular ejection fraction was 50.15%. The incidence of CIED-associated TR was 24% (95% confidence interval [CI] 20% to 28%, p <0.001) with an odds ratio of 2.44 (95% CI 1.58 to 3.77, p <0.001). CIED-associated TR was independently associated with an increased risk of all-cause mortality (adjusted hazard ratio [aHR] 1.52, 95% CI 1.36 to 1.69, p <0.001), heart failure (HF) hospitalizations (aHR 1.82, 95% CI 1.19 to 2.78, p = 0.006), and the composite of mortality and HF hospitalizations (aHR 1.96, 95% CI 1.33 to 2.87, p = 0.001) in the follow-up period. In conclusion, CIED-associated TR occurred in nearly one-fourth of patients after device implantation and was associated with an increased risk of all-cause mortality and HF hospitalizations.
Acute impact of atrial fibrillation on pacemaker lead-induced tricuspid regurgitation: Case report
2023, Journal of Cardiology Cases
We report a case of worsening lead-induced tricuspid regurgitation (TR) after new-onset atrial fibrillation (AF) evaluated using three-dimensional (3D) transthoracic echocardiography (TTE) from admission through TR improvement. An 84-year-old man experienced worsening lead-induced TR with new-onset AF, acutely resulting in low output syndrome. Less invasive interventions, such as rhythm control therapy and diuretics administration worked effectively. However, 3DTTE revealed consistent restricted motion of the septal leaflet with lead impingement. Right heart dilatation due to AF and worsened TR led to incomplete closure of other leaflets and tricuspid annular dilatation, which caused further deterioration of the TR. According to the course of our case, new-onset AF can cause acute worsening of lead-induced TR and low output syndrome in patients with cardiac implantable electronic devices (CIED). Our findings emphasize the importance of understanding the TR etiology in patients with CIED, which may prevent unnecessary CIED lead extraction.
Lead-induced tricuspid regurgitation (TR) can acutely deteriorate after new onset of atrial fibrillation (AF). AF-induced deterioration of TR may not depend on restricted motion of a leaflet with lead impingement but on incomplete closure of other leaflets caused by right heart and tricuspid annular dilatation. Rhythm control therapy and diuretics administration may improve AF-induced deterioration of lead-induced TR, and should be considered before performing invasive lead extractions.
Impact of lead position on tricuspid regurgitation, ventricular function, and heart failure exacerbation and mortality after cardiac implantable electronic device implantation. Preliminary results from the PACE-RVTR Registry
2024, Kardiologia Polska
Tricuspid Regurgitation (TR) after Implantation of a Cardiac Implantable Electronic Device (CIED)—One-Year Observation of Patients with or without Left Ventricular Dysfunction
2023, Journal of Cardiovascular Development and Disease
Identification of Pacemaker Lead Position Using Fluoroscopy to Avoid Significant Tricuspid Regurgitation
2023, Journal of Clinical Medicine
Lead-related tricuspid regurgitation and ventricle dysfunction: Current management and future perspectives
2023, Advances in Clinical and Experimental Medicine

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Comparison of Outcomes in Patients With Heart Failure With Versus Without Lead-Induced Tricuspid Regurgitation After Cardiac Implantable Electronic Devices Implantations

Highlights

Section snippets

Methods

Results

Discussion

The contribution of each author is as fllows

Declaration of Interests

J Am Coll Cardiol

J Am Soc Echocardiogr

Am J Cardiol

JACC Cardiovasc Imaging

J Am Soc Echocardiogr

JACC Cardiovasc Imaging

J Am Coll Cardiol

J Am Coll Cardiol