Delayed transvenous lead removal may boost risk of tricuspid regurgitation
Increases in tricuspid regurgitation (TR) severity occurred in 11.5 percent of patients following transvenous lead extraction, according to a single-center study, which also identified lead age as an important predictor of acute TR increases and tricuspid valve injury.
“Transvenous lead extraction (TLE) is established as a safe and effective method of lead removal with a high rate of procedural success and a low level of major complications,” wrote Cleveland Clinic researchers led by Seung-Jung Park, MD, PhD, in JACC: Clinical Electrophysiology. “However, TLE procedures are potentially complicated by significant tricuspid valve (TV) injury with a subsequent increase in tricuspid regurgitation. This occurs when the extensive fibrotic adhesions between leads implanted on a long basis and between the lead and the TV apparatus are disrupted.”
Park and colleagues studied 208 patients with implantable pacemakers or defibrillators who received TLE at the Cleveland Clinic from July 2014 through December 2016. These procedures are commonly performed for system revisions or upgrades, lead failures and device infections, the authors said.
Because lead extractions are frequently monitored by transesophageal echocardiography (TEE), the researchers used TEE to detect changes in tricuspid regurgitation following the extraction procedures.
Overall, 266 ventricular leads were extracted from the patients, with a mean lead age of 11.8 years.
Upon multivariable analysis, each increasing quartile of lead age was independently associated with 5 percent greater odds of acute TR increases, defined as an increase of at least one grade of regurgitation severity and a post-extraction severity rated as moderate or greater. Seven of the patients with TR increases (29 percent) had valve damaged detected by TEE, compared to no patients in the group without TR increases.
“In our data, there was a trend toward an increased risk of acute TR aggravation in patients with extraction of ≥3 (right ventricular) leads or use of ≥2 extraction tools,” the authors noted. “All these factors, along with a longer lead age, may be associated with more dense fibrotic adhesion and a greater risk of TV injury during TLE.”
Extracting a pacing lead was linked to 2.18 times the risk of significant TR increase versus extracting a defibrillator lead alone or both defibrillator and pacing leads.
Also, hospital stays lasted a median 6.5 days after TLE for patients who experienced significant TR increases—3.5 days longer than for individuals without that complication.
“The risk of TR aggravation seems to increase with lead age even 10 years after device implantation,” Park et al. wrote. “In addition, TLE-related TR aggravation could also lead to longer hospital stays, right-sided heart failure, and worse long-term prognosis.
“The strategic use of lead abandonment instead of earlier TLE increases implantation duration and likely raises the risk of TR (increase), a consequence that should be considered. Therefore, the alternative strategy of earlier TLE during cardiac device revision, replacement, or upgrade may be more attractive.”
Park and coauthors pointed out this was a short-term study and therefore unable to assess the impact of acute TR increases on long-term tricuspid valve status. They suggested a multicenter study with a larger sample size be undertaken to further explore the causes of TLE-related TR and its impact on long-term clinical events such as tricuspid valve repair or replacement and right-sided heart failure.
Daniel joined TriMed’s Chicago editorial team in 2017 as a Cardiovascular Business writer. He previously worked as a writer for daily newspapers in North Dakota and Indiana.