Management and Outcomes of Transvenous Pacing Leads in Patients Undergoing Transcatheter Tricuspid Valve Replacement
Anderson JH, McElhinney DB, Aboulhosn J, Zhang Y, Ribichini F, Eicken A, Whisenant B, Jones T, Kornowski R, Dvir D, Cabalka AK; VIVID Registry
JACC Cardiovasc Interv. 2020 Sep 14;13(17):2012-2020. doi: 10.1016/j.jcin.2020.04.054. Epub 2020 Aug 12.PMID: 32800497
Take Home Points:
- Transcatheter tricuspid valve replacement (TTVR) in the setting of transvenous right ventricular pacemaker leads is feasible and safe.
- Intra-procedural and long-term attention should be given to transvenous lead dysfunction following intentional lead entrapment by TTVR.
- There was no significant difference in cumulative incidence of death, TV reintervention, or TV dysfunction on medium-term follow-up of patients with and without pacing leads or entrapped RV leads.
Commentary from Dr. Arash Salavitabar (Ann Arbor, USA), section editor of Congenital Heart Disease Interventions Journal Watch: The authors aimed to answer an important question that often can help decide whether a patient requires transcatheter versus surgical replacement of a tricuspid valve, which is the prevalence of transvenous pacemaker lead complications following transcatheter tricuspid valve replacement (TTVR). This study was performed through the Valve-in-Valve International Database (VIVID) registry and retrospectively analyzed 329 patients who underwent TTVR following surgical TV repair or replacement. Three groups were compared: no lead (n=201), epicardial lead (n=70), and transvenous lead (n=58), with particular focus on those requiring entrapment of transvenous RV leads (see Central Illustration below). Patients who underwent catheterization with intention but without attempt at valve implantation were excluded. The most common type of previous surgical implant was a bioprosthetic valve and most common indication for TTVR was predominantly TR in all 3 groups. Patients with epicardial pacing systems were younger at TTVR (p=0.009), had more prior cardiac surgical procedures (p<0.001), were more likely to have prior bioprosthetic surgical implants (p=0.008), and surgical valve size <29mm (p=0.006).
In the 58 patients with a transvenous pacing system who underwent TTVR, the RV lead was entrapped between the TTV and surgical valve/ring in 28. Of the remaining patients, 17 had no RV lead, 10 had a RV lead between the true TV annulus and surgical valve (external to surgical valve), and 3 had the RV lead extracted prior to TTVR. Sapien valves (Edwards Lifesciences) were the predominant transcatheter valve implanted in those with transvenous pacemaker leads. There was a median follow-up period of 15.2 months post-TTVR in these patients.
Only 1 patient had a technical modification made related to lead entrapment in order to implant a TTV, which was placement of a covered pre-stent prior to TTVR. Three of 28 patients (10.7%) with intentional RV lead entrapment had complications: lead dislodgment (n=1, TTVR into annuloplasty ring), marked increase in RV lead impedance/stimulation threshold 2 weeks post-TTVR (n=1, TTVR within prior surgical valve), and RV lead fracture 7 months post-TTVR (n=1, TTVR within prior surgical valve). The last of those patients was noted to have early valve failure of the TTV with evidence of thrombus and required surgical valve and RV lead replacement. Procedural outcomes did not differ between patients who did and did not have intentional RV lead entrapment.
This study showed that no significant valvular complications were encountered during the peri-procedural or limited follow-up period in this cohort. There was a 7% incidence of RV lead failure in this study at 15.2 months follow-up, which exceeds the rate epicardial lead failure in adults and argues that increased surveillance of these leads is likely warranted after TTVR. The authors admit that longer follow-up will be necessary to determine whether patients who undergo TTVR in the setting of transvenous pacing leads are at risk for accelerated valve dysfunction. However, this study nicely shows that while interventional cardiologists must be aware of the potential complications of transvenous lead dysfunction during and after TTVR, the overall risks of lead and valvular dysfunction are low. While this decision is likely to be individualized until long-term outcomes are better understood, this is a promising option that may be preferable to surgery in many select patients.