860 TRICUSPID REGURGITATION RELATED TO CARDIAC IMPLANTABLE DEVICES: A NEW ENTITY?


 Background. The incidence of cardiac implantable electronic device (CIED) implantation is currently growing. Patients who develop a moderate to severe CIED-induced tricuspid regurgitation (TR) are at higher risk of pulmonary hypertension, right heart failure (HR) and have higher mortality. Transthoracic echocardiography (TTE) is the most common method for TR grading, while transesophageal echocardiography (TOE) with three-dimensional (3D) imaging is nowadays gaining importance to reconstruct valve morphology and to determine the TR pathophysiology.
 Case Summary. We present the case of an 83-year-old man with multiple comorbidities, affected by non-ischemic dilated cardiomyopathy, for which a biventricular defibrillator (ICD-CRT) was implanted in 2007 in primary prevention. Over the years, the patient has been a CRT-responder, with partial recovery of the ejection fraction (40% in 2022 versus 25%). In 2018 he had an episode of acute pulmonary oedema and ventricular fibrillation with ICD intervention; during that hospitalization, the right ventricular catheter (EC) was replaced due to dysfunction. In 2022, the patient presented to our hospital for anasarca due to right HF. TTE and TOE showed new onset of right heart dilation and dysfunction with severe TR, which was predominantly caused from lead impingement of the septal tricuspid valve (TV) leaflet and later from secondary dilation of the TV annulus. The patient responded well to medical therapy and was discharged.
 Discussion. CIED-related TR is getting more relevant since its growing prevalence and its prognostic impact, even if little is known about why some patients develop moderate-to-severe CIED-related TR. Clinicians should be aware of this entity and follow the patients with TR over the time with periodic echocardiograms. TOE and 3D imaging should always be performed to understand the mechanism of the TR and to select the optimal treatment. Currently, no guidelines nor randomized data are available in order to guide treatment in these patients. Figure 1:4-chamber views with and without color Doppler showing the ventricular EC passing the TV through with the presence of peri-catheter TR.Figure 2:trans-gastric TOE xPlane views showing how the ventricular EC determines a restrictive movement of the septal TV leaflet, causing the severe TR to form.