Incidence, predictors and outcome of severe tricuspid regurgitation after transvenous lead extraction: real-world experience from a Swiss nationwide cohort study

Background Transvenous lead extraction (TLE) is increasingly performed due to the growing population with cardiac implantable electronic devices. Severe tricuspid regurgitation (TR) is a major complication of TLE that is associated with increased heart failure events and mortality. Purpose To investigate the incidence, predictors and outcome of severe TR after TLE. Methods This Swiss nationwide cohort study included 638 patients with a planned extraction procedure for at least one transvenous lead with a dwell duration ≥12 months or the use of a dedicated extraction tool, and without severe TR at baseline. Differences between patients with and without severe tricuspid regurgitation after TLE were compared and univariable logistic regression was performed to identify patient characteristics associated with severe tricuspid regurgitation. Results The median age was 70 years (interquartile range [IQR] 60-78) and 30% were female. Severe TR after TLE was detected in 6 patients (1%). Patients who developed severe TR were more likely to have dilated cardiomyopathy (3 [50%] vs. 99 [16%], p=0.022), had a lower left ventricular ejection fraction (35% [30-45%] vs. 50% [36.5-60%], p=0.033) and a higher prevalence of moderate TR (4 [67%] vs. 84 [13%], p=<0.001) before TLE. Furthermore, they more often had two right atrial leads (1 [17%] vs. 9 [1%], p=0.003), ≥2 right ventricular leads (2 [33%] vs. 49 [8%], p=0.021), a right ventricular single- or dual-coil lead (5 [83%] vs. 201 [35%], p=0.014) and a coronary sinus lead (3 [50%] vs. 108 [17%], p=0.034) implanted. In patients who developed severe TR, laser sheaths were more often used for TLE of the right ventricular (2 [33%] vs. 40 [7%], p=0.013) and the coronary sinus lead (1 out of 3 [33%] vs. 3 out of 108 patients [3%], p=0.005). Finally, patients who developed severe TR after TLE, were more likely to suffer from procedure-related death (1 [17%] vs. 5 [1%], p<0.001). Univariable logistic regression revealed that predictors for the development of severe TR included the presence of dilated cardiomyopathy (odds ratio [OR] 5.38, confidence interval [CI] 1.07-27.06, p=0.041), moderate TR before TLE (OR 13.05, CI 2.35-72.35, p=0.003), two right atrial leads (OR 13.84, CI 1.47-130.78, p=0.022), ≥2 right ventricular leads (OR 5.95, CI 1.06-33.3, p=0.042), single- or dual-coil RV leads (OR 9.33, CI 1.08-80.39, p=0.042), and the use of a laser sheath for TLE of the right ventricular lead (OR 6.7, CI 1.19-37.7, p=0.031) and coronary sinus lead (OR 17.5, CI 1.22-250.36, p=0.035). Conclusion Development of severe TR after TLE is rare. The presence of dilated cardiomyopathy and moderate TR, as well as the presence of more implanted leads and the use of laser sheaths were associated with the development of severe TR. Patients with severe TR were more likely to experience procedure-related death.