Diagnosis of lead-induced tricuspid regurgitation

Introduction Clinically important lead-induced tricuspid regurgitation (LITR) is an uncommon complication following cardiac device implantation. Surgical removal and replacement of a lead may improve heart failure caused by LITR. Percutaneous lead extraction and reimplantation may also improve or correct LITR. However, whether severe tricuspid regurgitation (TR) is caused by a lead is often unclear, especially in patients with left ventricular (LV) dysfunction; worsening heart failure in such patients is most often attributed to progression of LV dysfunction. Echocardiography may clarify whether worsening heart failure is due to LITR. It is only occasionally obvious that a lead is the culprit. However, other findings may still implicate the lead. Right heart failure disproportionate to that expected for the degree of LV dysfunction should suggest possible LITR. In left heart failure, LV enddiastolic pressure (LVEDP) is expected to be greater than right ventricular (RV) end-diastolic pressure (RVEDP): the positive transseptal pressure gradient ( LVEDP RVEDP) would cause the ventricular septum to be concave toward the LV. If the ventricular septum is flattened, the transseptal pressure gradient is close to zero or negative; that is, RVEDP is greater than or equal to LVEDP. This should suggest other possible causes of RV failure, including LITR. Our experience suggests that the reasoning described above can help determine whether the lead is responsible for, or contributes to, severe TR and that percutaneous lead reimplantation may be beneficial.