Tricuspid Regurgitation in the Setting of Cardiac Implantable Electronic Devices

Figures

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  Figure 1. Echocardiography demonstrating device-related severe tricuspid regurgitation. (a) Apical 4 chamber view showing the ventricular lead adjacent to the septal leaflet of the tricuspid valve. (b) Three-dimensional echocardiographic view constructed from transesophageal images showing a surgeon’s view of the tricuspid valve with the device lead impinging on the septal leaflet with (c) resultant severe tricuspid regurgitation.

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  Figure 2. (a) Percutaneous tricuspid valve repair with MitraClip. (b) Triple-orifice technique. (c) Bicuspidization approach. Reproduced with permission.65

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  Figure 3. A case representative of the challenges presented with CIED and tricuspid regurgitation. A 91-year-old male with atrial fibrillation, a mechanical mitral valve, and a pacemaker with a single right ventricular lead developed severe tricuspid regurgitation and congestive hepatopathy-related cirrhosis. He was referred for lead extraction, placement of a leadless pacemaker, and ultimately TEER of the tricuspid valve with three MitraClip devices. (a) Pre-extraction TEE revealing severe TR. (b) Postextraction TEE revealing disrupted tricuspid leaflets and severe TR. (c) Fluoroscopy during the TEER procedure showing placement of the second clip under TEE and ICE guidance. (d) ICE imaging showing two tricuspid leaflets being captured by a MitraClip and ultimately trace TR. (e) Final TEE imaging showing the three MitraClips, pulling all three leaflets together, and the resulting trace TR. (f) Final chest X-ray showing the three MitraClips and the leadless pacemaker Abbreviations: CIED, cardiac implantable electronic device; ICE, intracardiac echocardiography; TEE, trans-esophageal echocardiography; TEER, transcatheter edge-to-edge repair; TR, tricuspid regurgitation.

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  Figure 4. Schematic illustration of the EVOQUE transcatheter tricuspid valve. Image was reproduced with permission from Edwards Lifesciences Corporation.

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  Figure 5. (a) Posteroanterior/lateral chest X-ray from a patient with tetrology of Fallot with atrial and ventricular arrhythmias who had a hybrid endocardial and epicardial defibrillator implanted. There are also superior vena cava, left pulmonary artery, and right ventricular outflow tract stents with a transcaether pulmonary valve replacement present. (b) Posteroanterior/lateral chest X-ray after a bioprosthetic tricuspid valve replacement (27 mm Magna Ease) demonstrating a defibrillator lead jailed by both the tricuspid valve replacement and the superior vena cava stent.

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  Figure 6. Steps of tricuspid valve repair. (1) Mobilized lead and leaflets of the tricuspid valve. (2) Lead repositioned in the cleft between the septal and inferior and posterior leaflets, with suture approximation of the leaflets above the cleft. (3) Repositioned lead with cleft closure and tricuspid valve annuloplasty.66

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  Figure 7. Aveir dual-chamber leadless pacemaker. (a) Atrial (left) and ventricular (right) Aveir leadless pacemaker devices are shown. (b) Schematic representation of the Aveir dual-chamber leadless pacemaker system once implanted. (c) An anterior-posterior chest X-ray projection showing the Aveir dual-chamber leadless pacemaker system immediately postimplant. Images reproduced with permission from Abbott Laboratories.

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  Figure 8. Aurora extra-vascular implantable cardioverter defibrillator is shown (a) ex vivo and (b) schematically following implantation. (c) and (d) show posterior-anterior and lateral projections, respectively, in a patient with the Aurora device implanted. Images used with permission from Medtronic, plc, 2024.

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  Figure 9. Tricuspid valve sparring options for cardiac implantable electronic devices that can pace and/or defibrillate Abbreviation: ICD, implantable cardioverter defibrillator.