Effect of Right Ventricular Endocardial Versus Epicardial Leads on Outcomes in Patients With Tricuspid Valve Prosthesis

INTRODUCTION: Endocardial right ventricular (EnRV) leads are described as a potential cause of native tricuspid valve regurgitation (TR). Need for cardiac pacing after tricuspid valve surgery is common, but little is known about the postoperative consequences of EnRV compared to epicardial right ventricular (EpiRV) lead implantation after tricuspid valve repair (TVr) or bioprosthetic tricuspid valve replacement (bTVR). This study aimed to assess TR, lead function, and risk of infection in patients with a tricuspid valve prosthesis followed by EnRV versus EpiRV lead implant. METHODS: We retrospectively reviewed all patients with RV lead post-TVr or bTVR at our hospital between January 2000 and January 2022. These were divided into two groups: Group 1 included patients with EnRV lead and Group 2 included patients with EpiRV lead. The primary outcome was the change in TR and RV lead function at follow-up. Level of TR was scored as 0 = none/trivial, 1 = mild, 2 = moderate, and 3 = severe. Pacing threshold change (ΔV ± SD), need for revision or extraction, and death at follow-up were noted. RESULTS: Sixty-five patients were identified: Group 1 included 53 patients (56% female, 81% atrial fibrillation, 94% TVr, and 6% bTVR) and Group 2 included 12 patients (67% female, 42% atrial fibrillation, 42% TVr, and 58% bTVR). In Group 2, 58% had a prior RV lead extracted intraoperatively due to lead-related TR versus 0% in Group 1. In Group 1, the mean time from surgery to RV lead implant, last echocardiogram, and last device interrogation were 24, 52, and 72 months respectively, versus 0, 62, and 63 months for Group 2, respectively. TR worsened in Group 1 in 55% of TVr patients (mean 0.97 level). When compared to Group 2, worsening TR was significantly higher in Group 1 versus Group 2 (p = 0.028), particularly after TVr and not bTVR. Nine patients (18%) in Group 1 had worsening TR to moderate severity compared to 0 patients in Group 2. RV lead threshold significantly worsened in Group 2 versus Group 1 (55.5% vs. 3.7%, p = 0.003); RV threshold increased significantly by Δ 1.18 ± 2.05 V versus Δ 0.11 ± 0.34 V (p = 0.026). The average threshold at follow-up in Group 2 was 2.02 ± 2.13 V versus 0.74 ± 0.27 V for Group 1 (p = 0.003). Lead extraction occurred in 8% of patients in Group 1 (25% endocarditis and 75% lead failure/malfunction) and 17% in Group 2 (100% endocarditis). There was a total of 29 deaths (Group 1: 43%, mean follow-up of 72 months vs. Group 2: 50%, mean follow-up of 63 months, p = 0.754). CONCLUSION: Presence of EnRV lead after TV surgery correlated with a mild increase in TR after TVr but not bTVR. Compared to EnRV leads, EpiRV lead threshold increased significantly over time compared to EnRV leads. EnRV lead is a suitable approach after TVr or bTVR.