Tricuspid valve regurgitation in the presence of endocardial leads – an underestimated problem

Introduction

In about 80% of the population, a small degree of tricuspid insufficiency occurs and therefore is considered almost physiological [1]. Higher mortality has been described among patients with moderate and severe tricuspid regurgitation compared to patients without it, irrespective of the pulmonary pressure value or systolic function of the left and right ventricle [2–4]. A fourfold increase in the risk of substantial tricuspid regurgitation is caused by the presence of the endocardial lead [5].
A chest X-ray examination is used in order to assess the position of the lead in the heart [6]. The influence of endocardial lead position in the chest X-ray on tricuspid valve function and the presence of its insufficiency has not yet been described in the literature.

Aim

The aim of the study was to determine the correlation between the radiological endocardial lead position and the tricuspid valve regurgitation severity.

Material and methods

The study comprised 100 consecutive, random patients who were admitted to the outpatient clinic between November 2013 and September 2014 for a routine follow-up after cardiac stimulation system implantation. There were no data available about their pre-implantation echocardiographic examination or the lead position directly after implantation.
Inclusion criteria: patient after cardiac stimulation system implantation; and, conscious consent for the trial.
Exclusion criteria: severe mitral valve insufficiency and mitral valve prosthesis.
The patient’s chest X-ray was taken in the postero-anterior (PA) and lateral position, and transthoracic echocardiography was performed.
The authors introduced the definitions of optimal and non-optimal lead position.
An optimal lead position in the PA radiological picture was defined as its free transition through the right heart chambers and through the tricuspid valve as an arch with its curve facing the diaphragm.
An excessive lead length was defined as its double-crossing through the valve or creating a loop at the valve level (Figure 1 A), transition of two parallel leads through the valve creating an expansion mechanism (Figure 1 B), or excessive lead length in the right atrium with the lead loop surrounding the inferior wall of the atrium and creating an arch facing upright at the tricuspid valve level (Figure 1 C).
Insufficient lead length was defined as excessive strengthening of the lead at the...


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