303 IMPACT OF LEAD POSITION IN THE TRICUSPID ANULUS ON THE DEVELOPMENT OF CARDIAC IMPLANTABLE ELECTRONIC DEVICES RELATED TRICUSPID REGURGITATION


 
 
 Originally considered as the “forgotten valve disease”, tricuspid regurgitation (TR) has recently been shown to correlate with consistent morbidity and mortality, suggesting the need for a deeper understanding of its natural course. Direct injury from Cardiac Implantable Electrical Device (CIED) leads is one of the most common causes of primary TR, with a prevalence up to 40%. The aim of the present proof-of-concept study was to evaluate the effect of CIED right ventricular (RV) lead position within the tricuspid anulus on TR development.
 
 
 
 Consecutive patients undergoing CIED implantation at our institution (Humanitas Research Horpital IRCCS, Milan, Italy) were included, as long as they had been performed pre- and post- transthoracic echocardiogram (TTE) and a chest CT scan after the implantation. TTE and CT images were retrospectively reviewed. TR severity was graded using a pre-specified 4-class grading scheme: mild, moderate, severe and massive. CIED RV lead position was defined as postero-septal, antero-septal or antero-posterior, based on the commissure in which the lead was observed on a cross-sectional view of the tricuspid anulus at CT scan.
 
 
 
 64 patients undergoing CIED implantation from January 2015 to December 2021 were included. All CT scans were non-ECG gated. TR was detected in 42 patients (65.62%) at pre-implantation TTE. The RV lead was implanted across the postero-septal, antero-posterior and antero-septal commissures in 35 (54.7%), 16 (25%) and 13 (20.3%) patients respectively. After the implantation, 12 individuals (18.75%) had new-onset or worsening TR, with CIED lead contributing to TR in 46.88% of cases (30/64), and 26 (40.63%) had worse RV function. At logistic regression analysis, the absence of atrial fibrillation was the only independent predictor of new-onset or worsening TR (OR: 0.17, 95% CI: 0.03-0.86, p=0.032), while CIED RV lead in the postero-septal commissure was associated with a numerically lower risk as compared to other sites (OR: 0.34, 95% CI: 0.09-1.27, p=0.108). Consistently, the degree of increase in TR severity was numerically lower in patients with a lead in the postero-septal commissure (Δ = 0.38±0.10 vs. 0.63±0.13, p=0.07).
 
 
 
 CIED implantation is associated with increasing TR severity and worsening RV function. Positioning a lead across the postero-septal commissure of the tricuspid anulus might have a lower impact on TR development and worsening, thus representing a feasible option to prevent CIED-related TR.
