Lead management in patients undergoing percutaneous tricuspid valve replacement or repair: a 'heart team' approach

Clinically significant tricuspid regurgitation (TR) has historically been managed with either medical therapy or surgical interventions. More recently, percutaneous trans-catheter tricuspid valve (TV) replacement and tricuspid trans-catheter edge-to-edge repair have emerged as alternative treatment modalities. Patients with cardiac implantable electronic devices (CIEDs) have an increased incidence of TR. Severe TR in this population can occur for multiple reasons but most often results from the interactions between the CIED lead and the TV apparatus. Management decisions in patients with CIED leads and clinically significant TR, who are undergoing evaluation for a percutaneous TV intervention, need careful consideration as a trans-venous lead extraction (TLE) may both worsen and improve TR severity. Furthermore, given the potential risks of 'jailing' a CIED lead at the time of a percutaneous TV intervention (lead fracture and risk of subsequent infections), consideration should be given to performing a TLE prior to a percutaneous TV intervention. The purpose of this 'state-of-the-art' review is to provide an overview of the causes of TR in patients with CIEDs, discuss the available therapeutic options for patients with TR and CIED leads, and advocate for including a lead management specialist as a member of the 'heart team' when making treatment decisions in patients TR and CIED leads. Graphical Abstract Flow diagram of a 'heart team' approach to managing severe symptomatic tricuspid regurgitation. CIED, cardiac implantable electronic device; CS, coronary sinus; EV-ICD, extravascular ICD; ICD, implantable cardioverter defibrillator; ICE, intra-cardiac echocardiography; LP, leadless pacemaker; LV, left ventricle; PPM, pacemaker; RV, right ventricle; S-ICD, subcutaneous ICD; TEE, trans-oesophageal echocardiography; TR, tricuspid regurgitation; TV, tricuspid valve.