Management of Cardiac Implantable Electronic Devices in Patients With Severe Symptomatic Tricuspid Regurgitation—Proposed Algorithm and Selected Case Examples

Severe tricuspid regurgitation (TR) is associated with significant morbidity and mortality. Management of severe TR includes treatment of the underlying cause(s), medical therapy and less commonly surgical tricuspid valve repair. Newer transcatheter tricuspid valve repair devices show promise for those patients who remain symptomatic with severe TR despite such efforts. The presence of a Cardiac Implantable Electronic Device (CIED) with leads across the tricuspid valve poses a significant challenge from both diagnostic and therapeutic standpoints. In this paper, we propose an algorithm to manage patients with CIED leads across the tricuspid valve and symptomatic TR. We include case studies to illustrate implementation of the algorithm in clinical care. Key takeaway messages: (1) CIED leads across the tricuspid valve (TV) in the setting of TR are often innocent but may be causal and/or interfere with valve imaging. (2) CIED lead extraction often does not reduce TR and is reserved for select patients. (3)Transcatheter TV interventions can be performed in the presence of CIED leads. (4) An algorithm-driven interventional cardiology, electrophysiology and advanced imaging team approach is needed to best manage TR in the setting of CIED leads.