Outcomes of entrapped right ventricular pacing or defibrillator leads following transcatheter tricuspid valve replacement

Background In patients with a cardiac implantable electrical device (CIED) using a transvenous right ventricular (RV) lead, transcatheter tricuspid valve replacement (TTVR) results in RV lead entrapment. Objectives Evaluate outcomes of patients with a preexisting transvenous RV lead undergoing EVOQUE TTVR. Methods Patients with a CIED referred for TTVR at three centers were evaluated preoperatively by the Heart Team, including an electrophysiologist. Lead assessments were performed at baseline, immediately post-TTVR, and in follow-up. Results Of 146 EVOQUE TTVR patients, 52 consecutive patients with entrapped RV leads (81 [77-85] years-old; 63.5% female, lead dwell time 8.9 [3.3-13.6] years) were evaluated. Tricuspid regurgitation (TR) was related to the CIED lead in 88.5%. 30-days post-TTVR, residual valvular TR was mild-or-less in all patients, and paravalvular leak was mild-or-less in 98%. Four patients had procedure-related lead complications. 1) Intraprocedural RV lead dislodgement. The patient underwent emergent implantation of a coronary sinus pacing lead which has been functioning normally for >4 years. 2) ICD lead fracture 8 weeks post-TTVR. The patient no longer had an indication for a defibrillator due to improved left ventricular ejection fraction and underwent leadless pacemaker implant. 3) ICD lead fracture 6 weeks post-TTVR followed by implantation of a subcutaneous ICD. 4) MSSA endocarditis 1-month post-TTVR complicated by antibiotic-induced kidney injury and death. Of the 33 patients without complications who had follow up >30 days (424 [182-1006] days) one additional patient required reprogramming due to RV lead noise. There was a significant decrease in lead impedance and increase in capture threshold on the final lead assessment compared to pre-procedure values, but no additional patients required lead revision. Conclusions Following TTVR, most with entrapped RV leads remain free of lead-related adverse events. The need for urgent CIED revision due to RV lead dislodgment or failure is uncommon, but may occur. There were statistically significant, but not clinically impactful, changes in pacing thresholds and impedance through long-term follow-up.