Severe Symptomatic Tricuspid Valve Regurgitation due to Permanent Pacemaker or Implantable Cardioverter-Defibrillator Leads

Background:
Severe tricuspid regurgitation (TR) caused by a Permanent Pacemaker (PPM) or Implantable Cardioverter-Defibrillator (ICD) lead is an under-recognized but treatable etiology of severe right heart failure.

Objectives:
We report a series of patients with severe TR due to a PPM or ICD lead.

Methods:
We reviewed the records of 18 patients who underwent tricuspid valve (TV) operation for severe TR caused by previously placed PPM or ICD leads.

Results:
Of a total of 770 patients who underwent TV surgery, 75 patients had a previously trans-TV AICD or PPM leads implanted. In 18 patients the direct cause for severe TR was identified to be the PPM or AICD leads. All patients suffered from severe right heart failure and had various degrees of RV dysfunction.

In surgery, a perforation of the tricuspid valve leaflet by the PPM or ICD lead was found in 6 patients and lead adherence to the tricuspid valve occurred in 12 patients In the preoperative evaluation, valve malfunction due to the PPM or ICD lead was diagnosed preoperatively in only 4 of 18 (22 %) patients by transthoracic echocardiography. All patients underwent successful tricuspid valve operation; most underwent TV repair. Sixten patients (88%) underwent concomitant procedures. There was no perioperative death. The mean hospital stay was 15 days. During follow-up (range, 1 to 109 months), there was 1 patient who died from a non-cardiac cause and 4 patients died from unknown cause. Twenty percent of the patients suffered from significant symptoms of heart failure..

Conclusions:
Damage to the tricuspid valve by PPM or ICD leads may result in severe symptomatic TR and may not be overtly visualized by echocardiography. This type of TR mechanism is probably under-diagnosed and should be always thoroughly investigated using 3D echo when evaluating patients with TR after PPM or ICD implantation.