Late resolution of pacemaker lead–related severe tricuspid regurgitation and right ventricular dysfunction after percutaneous lead extraction: A case report and review of the literature

Introduction Endocardial lead–related tricuspid regurgitation (ELTR) is an increasingly recognized complication of cardiac device implantation that can result in right ventricular (RV) dysfunction and right heart failure. Several mechanisms of ELTR have been proposed, including lead impingement on tricuspid valve (TV) leaflets; leaflet perforation; entanglement within the valve apparatus; adherence to TV leaflets, chordae, or papillary muscles; and altered RV activation or geometry owing to RV pacing. Irrespective of the mechanism(s) involved, it has been postulated that the mechanical and hemodynamic consequences of ELTR on the TV and RV should manifest by 6 months post–device implantation, delineating the time period during which compatible signs and symptoms should most raise suspicion for this condition and suggesting that early intervention may be important. Though both surgical and percutaneous treatment options for ELTR have been reported, surgery has been advocated as the default treatment by some, in part because of a perceived high risk of procedural complications with percutaneous options, including damage to the TV. However, case series of patients undergoing TV surgery for isolated severe tricuspid regurgitation (TR), including cases of ELTR, have reported considerable operative morbidity and short-term mortality as high as 19%. In contrast, major complications occur in o0.8% of patients undergoing contemporary percutaneous lead removal at experienced centers and in as little as 0% of cases involving leads less than 1 year old. Nevertheless, the role of percutaneous interventions for ELTR remains unclear, with 3 reports suggesting unpredictable improvements in TR and RV function with this