Why the study?
Preexisting CIED transvalvular leads are common in TTVR candidates, raising concerns regarding the safety of lead entrapment versus the risks of transvenous lead extraction.
How should preexisting cardiac implantable electronic device (CIED) transvalvular leads be managed in patients with severe tricuspid regurgitation undergoing transcatheter tricuspid valve replacement (TTVR)?
How should preexisting cardiac implantable electronic device (CIED) transvalvular leads be managed in patients with severe tricuspid regurgitation undergoing transcatheter tricuspid valve replacement (TTVR)?
This consensus document provides a management algorithm for handling CIED leads in patients undergoing TTVR, highlighting the need for multidisciplinary heart team evaluation including an electrophysiologist.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“A heart team approach is mandatory, because these patients are very complicated and the leads may or may not be contributing to the TR. Heart failure physicians can help medically manage and optimize these patients. Imagers help us understand the anatomy and the relationship of the leads to the valve, and guide any interventional procedures.”
“A very high percentage of these patients already have a cardiac implantable electronic device with a transvenous lead in place across the tricuspid valve, or do not have a device and develop heart block after the procedure. This procedure has suddenly forced collaboration between interventionalists and electrophysiologists.”
Lead entrapment during TTVR shows low major complication rates; leaves open long-term durability and infection risks in larger cohorts.
Orthotopic transcatheter tricuspid valve replacement (TTVR) devices have been shown to be highly effective in reducing tricuspid regurgitation (TR), and interest in this therapy is growing with the recent commercial approval of the first orthotopic TTVR. Recent TTVR studies report preexisting cardiac implantable electronic device (CIED) transvalvular leads in ∼35% of patients, with entrapment during valve implantation. Concerns have been raised regarding the safety of entrapping leads and counterbalanced against the risks of transvenous lead extraction (TLE) when indicated. This Heart Valve Collaboratory consensus document attempts to define the patient population with CIED lead-associated or lead-induced TR, describe the risks of lead entrapment during TTVR, delineate the risks and benefits of TLE in this setting, and develop a management algorithm for patients considered for TTVR. An electrophysiologist experienced in CIED management should be part of the multidisciplinary heart team and involved in shared decision making.
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Hahn et al. (2024) conducted a review in Severe Tricuspid Regurgitation. Transcatheter tricuspid valve replacement (TTVR) and CIED management was evaluated. A Heart Valve Collaboratory consensus document outlines a management algorithm for the approximately 35% of patients undergoing transcatheter tricuspid valve replacement who have preexisting CIED leads.
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