The Impact of Transvenous Lead Extraction on Tricuspid Valve Function

Abstract Background Accidental damage of tricuspid apparatus is known complication of TLE procedure risk factors of this complication remain unknown. Purpose The goal of this study was to search factors which can predict damage of tricuspid apparatus during TLE. Methods Between 2006 and 2018 we performed 2002 TLE procedures using conventional mechanical sheaths. 3366 leads (mean implant duration 95,2 months) were removed due to non-infective indications in 62,0%. Tricuspid valve function was examined with preoperative and post-operative TTE and during monitoring of procedure. Patients with incomplete TV function evaluation were excluded from the study. Three groups of patients were compared Results TLE procedure brings risk (7%) of different degree damage or tricuspid leflet or even chordae tendinae (2%). The detailed results are presented in the table. Conclusions TLE using conventional mechanical sheaths is effective but brings risk of extraction related tricuspid valve dysfunction. Main risk factor of this complication seems to be implant dwell time, number of leads presence of abandoned leads and lead loop in the heart remaining in conflict with tricuspid valve.

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2407Influence of transvenous lead extraction procedure on function of tricuspid apparatus

European Heart Journal ◽

10.1093/eurheartj/ehz748.0160 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

A Polewczyk ◽

D Nowosielecka ◽

A Tomaszewski ◽

W Brzozowski ◽

D Szczesniak Stanczyk ◽

...

Keyword(s):

Tricuspid Valve ◽

Clinical Success ◽

Extraction Procedure ◽

Lead Extraction ◽

Lead Removal ◽

Separate Analysis ◽

Valve Dysfunction ◽

Valve Function ◽

Procedural Success

Abstract Background Accidental damage of tricuspid apparatus remain known complication of TLE procedure but our knowledge is limited due lack of separate analysis in the literature. Purpose The goal of this study was analysis of the appearance of lead extraction related tricuspid valve dysfunction using trans-chest and trans-oesophageal echocardiography. Methods Between March 2006 and December 2018 we performed 2900 TLE procedures using conventional mechanical sheaths in 1760 male and 1140 female patients (mean age 66.6y). 4811 leads (mean implant duration 91.5 months) were removed due to non-infective indications in 65.3%. Full radiological success was obtained in 95.7% procedures, partial in 4.0%, clinical success in 98.0%, full procedural success in 96.1%. Major complications (MC) appeared in 8 (1.8%). Results Results are presented in the table Conclusions TLE using conventional mechanical sheaths is effective. Tricuspid valve dysfunction different degree is frequent finding in candidates for TLE. TLE procedure brings risk (7.2%) of different degree damage of tricuspid leflet (significant in 1.5%) or even chordae tendinae (4%). Patients with severe lead extraction related tricuspid valve dysfunction needs exact follow-up and some of them can be candidates for cardiac surgery. On the other hand in not so rare cases of lead related tricuspid valve dysfunction – lead removal/replacement can to bring improvement of tricuspid valve function (6.1%).

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Retained Pacemaker Lead Fragment-Induced Fibrosis, Resulting in Impaired Tricuspid Valve Function, Managed with a Valve-Sparing Open Surgical Approach

Journal of Clinical Review & Case Reports ◽

10.33140/jcrc.06.06.05 ◽

2021 ◽

Vol 6 (6) ◽

Keyword(s):

Tricuspid Valve ◽

Surgical Approach ◽

Lead Extraction ◽

Pacemaker Lead ◽

Valve Function ◽

Symptomatic Bradycardia ◽

Pacemaker Insertion ◽

Open Surgical Approach

Retained pacemaker lead fragments can induce fibrosis which can affect valve function. In this case, a female patient in her fifties had undergone pacemaker insertion in her teens for symptomatic bradycardia. Due to pacemaker pocket erosion, she had undergone a lead extraction where lead fragments were left in-situ. Over time, she gradually developed symptomatic tricuspid dysfunction. Due to the severe impact on her quality of life, the patient opted for an open surgical approach. Intraoperatively, electrocautery was used to debride the fibrotic tissue inhibiting the leaflets of the tricuspid valve. This resulted in marked improvement of valve function and additional repair/replacement was not necessary. To our knowledge, such a case has not been previously described.

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Lead Dependent Tricuspid Valve Dysfunction-Risk Factors, Improvement after Transvenous Lead Extraction and Long-Term Prognosis

Journal of Clinical Medicine ◽

10.3390/jcm11010089 ◽

2021 ◽

Vol 11 (1) ◽

pp. 89

Author(s):

Anna Polewczyk ◽

Wojciech Jacheć ◽

Dorota Nowosielecka ◽

Andrzej Tomaszewski ◽

Wojciech Brzozowski ◽

...

Keyword(s):

Risk Factors ◽

Tricuspid Valve ◽

Lead Extraction ◽

Common Mechanism ◽

Term Survival ◽

Long Term Survival ◽

Valve Dysfunction ◽

Valve Function ◽

Long Term Prognosis

Background: Lead-related tricuspid valve dysfunction (LDTVD) has not been studied in a large population and its management remains controversial. Methods: An analysis of the clinical data of 2678 patients undergoing transvenous lead extraction (TLE) in years 2008–2021 was conducted, with a separate group of 119 patients with LDTVD. Potential risk factors for LDTVD, improvement in valve function, and long-term prognosis after TLE were assessed. Results: LDTVD was diagnosed in 4.44% of patients referred for lead extraction due to different reasons. The most common mechanism of LDTVD was propping upward or clamping down the leaflet by the lead (85.71%). The probability of LDTVD was higher in female sex, patients with valvular heart disease, atrial fibrillation, heart failure, large right ventricle and high pulmonary artery systolic pressure, the presence of only pacing lead, and in case of collision of the lead with tricuspid valve and adhesion of the lead to the heart structures. The prognosis of patients with LDTVD was worse, however, patients with improved valve function after TLE showed a significantly better long-term survival. Conclusions: Lead dependent tricuspid valve dysfunction is a potentially serious condition that requires thorough diagnostics and thoughtful management. The risk factors for LDTVD are primarily related to the course of the lead and its adhesion to the heart structures. Improvement of tricuspid valve function after TLE is observed in 35.29% of patients Patients with LDTVD have a worse long-term survival, but the improvement in valve function following TLE contributes to a significant reduction in mortality.

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The role of cardiac surgery in transvenous lead extraction (TLE) – experience from high volume center and 3207 procedures

European Heart Journal ◽

10.1093/ehjci/ehaa946.0836 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

L Tulecki ◽

M Czajkowski ◽

S Targonska ◽

K Tomkow ◽

D Nowosielecka ◽

...

Keyword(s):

Cardiac Surgery ◽

Tricuspid Valve ◽

Surgical Intervention ◽

Clinical Success ◽

Left Ventricular ◽

Lead Extraction ◽

Icd Leads ◽

Ventricular Lead ◽

Cardiac Surgeon

Abstract Background The guidelines suggest close co-operation between TLE operating team and cardiac surgery and its key role in the management of life-threatening complications remains unquestionable. But the role of cardiac surgeon seems to be much more extended. Purpose We have analysed the role of cardiac surgery in treatment of patients undergoing TLE procedures. Methods Using standard non-powered mechanical systems we have extracted ingrown PM/ICD leads from 3207 pts (38,7% female, average age 65,7-y) during the last 14 years. Non-infectious TLE indications were in 66,4% of patients. 46% had PM DDD system, 19% PM SSI, 22% ICD, 9% CRT, 4% other systems. In 12% of patients abandoned leads were found. 8% of patients had one lead, 54% - two, 15% - three and 4% - 4–6 leads in the heart. An average dwell time of all leads was 91,5 mth. The lead entry side was left in 96% of patients, right in 3% and both – 4%. Results Procedural success 96,1%, clinical success - 97,8%, procedure-related death 0,2%. Major complications appeared in 1,9% (cardiac tamponade 1,2%, haemothorax 0,2%, tricuspid valve damage 0,3%, stroke, pulmonary embolism <1%). Conclusions Rescue cardiac surgery (for severe haemorrhagic complications) is still the most frequent reason of surgical intervention (1,1%). The second area of co-operation includes supplementary cardiac surgery after (incomplete) TLE (0,8%). The third one is connected with reconstruction or replacement of tricuspid valve, which can be affected by ingrown lead or damaged during TLE procedure (0,5%). Implantation of the complete epicardial system during any surgical intervention (rescue or delayed) should be considered as a supplementation of the operation (0,65%). Some of patients after TLE need implantation of epicardial leads for permanent epicardial pacing (0,6%) and some only left ventricular lead to rebuild permanent cardiac resynchronisation (0,5%). The single experience of large TLE centre indicates the necessity of close co-operation with cardiac surgeon, whose role seems to be more comprehensive than a surgical stand-by itself. Table 1 Funding Acknowledgement Type of funding source: None

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Abstract 16979: Hemodynamic Comparison of Tricuspid Ring Annuloplasty vs. Hetzer Annuloplasty Technique to Repair Functional Tricuspid Regurgitation

Circulation ◽

10.1161/circ.142.suppl_3.16979 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Alan Amedi ◽

Daisuke Onohara ◽

Muralidhar Padala

Keyword(s):

Tricuspid Valve ◽

Tricuspid Regurgitation ◽

Ex Vivo ◽

Working Fluid ◽

Posterior Leaflet ◽

Anterior Leaflet ◽

Ex Vivo Model ◽

Functional Tricuspid Regurgitation ◽

Ring Annuloplasty ◽

Valve Function

Introduction: Surgical repair of functional tricuspid regurgitation (FTR) is increasingly performed, and the techniques are evolving. Annuloplasty is currently the technique of choice, with different techniques yielding varied results, and thus require optimization. Objective: In this study, we sought to compare tricuspid valve function and kinematics after ring annuloplasty and Hetzer’s double orifice repair in an ex vivo model of FTR. Methods: Ten pig hearts were mounted into a right heart simulator, and studied at 70 bpm while maintaining the total volume of working fluid. FTR was created by increasing afterload, which caused acute right ventricular dilation and TV tethering. Tricuspid valve annuloplasty (TVA) was performed with a 26mm MC 3 ring. Hetzer procedure was performed with pledgeted sutures that approximated the anteroposterior and septal annular segments. Flow probes were used to measure FTR, and leaflet kinematics with echocardiography. Results: FTR of 17.7±9.2mL(p<0.0001) after RV dilation. Repair with TVA and Hetzer reduced FTR to 8.8±6.8ml(p=0.7142) and 7.8±6.9ml(p=0.0919), respectively, but did not eliminate it. Septal leaflet excursion angle decreased by 48.1% with FTR (p=0.04 vs. baseline ) . Repair with TVA and Hetzer increased the angle to 17.3±6.7°(p=0.0312) and 21.5±8.3°(vs FTR, p=0.0034), respectively. The Hetzer improved septal leaflet mobility better than TVA (p=0.0145). The posterior leaflet excursion angle decreased by 49.2% compared to baseline to 18.4±10.5° (p=0.0060) and both TVA and Hetzer significantly improved mobility to 33.6±8.4° (p=0.0081) and 31.6±15.6° (p=0.0256), respectively. Anterior leaflet mobility decreased after FTR by 60.7% to 18.1±8.2°. The effect of these repairs on the sub-valvular apparatus was negligible. Conclusion: TVA and Hetzer both reduced regurgitation but did not eliminate it. Septal and posterior leaflet mobility was improved, while the anterior leaflet remained tethered.

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Abstract 16289: Deformation of Tricuspid Annulus After Tricuspid Ring Annuloplasty: A Three-dimensional Transesophageal Echocardiography Study

Circulation ◽

10.1161/circ.142.suppl_3.16289 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Atsushi Hayashi ◽

Jun Akashi ◽

Yosuke Nabeshima ◽

Mai Iwataki ◽

Yutaka Otsuji

Keyword(s):

Transesophageal Echocardiography ◽

Tricuspid Valve ◽

Heart Surgery ◽

Three Dimensional ◽

Tricuspid Annulus ◽

Annuloplasty Ring ◽

Functional Tricuspid Regurgitation ◽

Ring Annuloplasty ◽

Percent Area ◽

The Impact

Background: Tricuspid ring annuloplasty (TAP) is usually performed for patients with mild or greater functional tricuspid regurgitation (TR) at the time of left-sided valve surgery. However, there were limited data regarding the shape of tricuspid annulus after TAP. The aim of this study was using three-dimensional (3D) transesophageal echocardiography to investigate the impact of the ring annuloplasty on the tricuspid annulus after TAP. Methods: 3D tricuspid valve was retrospectively analyzed in 20 patients who underwent concomitant left-sided heart surgery and TAP for functional TR. 3D data of tricuspid valve were acquired before TAP, immediate after surgery (intraoperative), and before discharge (15±5 days after TAP). TAP was performed by one surgeon using a Carpentier-Edwards Physio Tricuspid annuloplasty ring. The ring size was determined by measuring the distance from anteroseptal to posteroseptal commissures. 3D tricuspid annular area was measured. The area protruded outside the annuloplasty ring was obtained by subtracting the ring area from the annular area (Figure). Results: All 20 patients underwent successfully TAP with less than mild residual TR. Annuloplasty rings size 28mm, 30mm, 32mm, and 34mm were used in 6 (30%), 4 (20%), 5 (25%), and 5 (25%) patients, respectively. Median annular area decreased from 1074 (interquartile rage 893-1276) mm 2 before TAP to 591 (519-706) mm 2 immediate after TAP, but showed significant increase to 645 (501-766) mm 2 at the time of discharge (P<0.001). Percent area protruded outside the annuloplasty ring was 14% immediate after TAP and increased to 24% before discharge (P<0.001). Before discharge, there were 9 patients with more than mild residual TR (2 had moderate TR). Percent area protruded outside the annuloplasty ring was associated with mild or more residual TR at the discharge. Conclusion: Tricuspid annular shape after TAP was not always round. Deformation of tricuspid annulus may be associated with residual TR.

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Jugular valve function and petrosal sinuses pressure: a computational model applied to sudden sensorineural hearing loss

Veins and Lymphatics ◽

10.4081/vl.2017.6707 ◽

2017 ◽

Vol 6 (2) ◽

Cited By ~ 1

Author(s):

Mirko Tessari ◽

Andrea Ciorba ◽

Lucas Omar Mueller ◽

Qinghui Zhang ◽

Mariapaola Cristini ◽

...

Keyword(s):

Mathematical Model ◽

Hearing Loss ◽

Sensorineural Hearing Loss ◽

Clinical Information ◽

Sudden Sensorineural Hearing Loss ◽

Sensorineural Hearing ◽

Mean Flow ◽

Venous Outflow ◽

Valve Function ◽

The Impact

Reports of extra-cranial venous outflow disturbances have recently been linked to sudden sensorineural hearing loss (SSNHL). Aims of the present study are: i) to quantify, with mathematical model, the impact of jugular valve function on the pressure of the superior and inferior petrosal sinuses (SPS, IPS) and the main auricolar veins; ii) to verify the feasibility of the application of mathematical model in the clinical setting in terms of consistency respect to the usual measures of SSNHL outcome. Extra-cranial venous outflow and post analysis were respectively blindly assessed by echo colour-Doppler (ECD) and a validated mathematical model for the human circulation. The pilot study was conducted on 1 healthy control and in a group of 4 patients with different outcome of SSNHL. The main finding was the significant increased pressure calculated in the SPS and IPS of patients with ipsilateral jugular obstruction due to not mobile valve leaflets (6.55 mmHg), respect to the other subjects without extracranial complete obstruction (6.01 mmHg), P=0.0006. Moreover, we demonstrated an inverted correlation between the extrapolated pressure values in the SPS/IPS and the mean flow measured in the correspondent internal jugular vein (r= –0.87773; r-squared= 0.7697; P=0.0009). The proposed mathematical model can be applied to venous extra-cranial ECD investigation in order to derive novel clinical information on the drainage of the inner ear. Such clinical information seems to provide coherent parameters potentially capable to drive the prognosis. This innovative approach was proven to be feasible by the present pilot investigation and warrants further studies with an increased sample of patients.

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