322 TRICUSPID VALVE REGURGITATION AFTER TRANSVENOUS LEAD EXTRACTION: WE NEED TO KNOW MORE


 Since 2003 a 73-year-old man was submitted to a pacemaker implantation because of atrio-ventricular block. After fourteen years, upgrading to CRT-D was made due to recovery for acute heart failure in a dilated cardiomyopathy with severe left ventricular systolic dysfunction. In 2019 and 2020 he presented pocket erosion therefore underwent to a submuscular reimplantation. After one year, he came to Arrhythmology outpatient appointment with inflammatory signs of the CRT-D pocket. The patient was started on Meropenem and Vancomicin. Transthoracic (TTE) and transesophageal echocardiogram didn't reveal any vegetation on valvular apparatus or on leads. The patient was submitted to transvenous lead extraction (TLE) with bidirectional rotational mechanical sheats and a epicardial lead on postero-lateral left ventricular wall was implanted. The post-procedural TTE showed a moderate to severe organic tricuspid valve regurgitation with annular dilatation despite the patient was asymptomatic. There weren't flail leaflets or tricuspid valve damage. The reimplantation of right atrial and ventricular leads was hindered by complex venous anatomy documented by intraprocedural phlebography. After Heart Team discussion, we agreed to tricuspid valve repair with annuloplasty ring and other two epicardial leads - right atrial and ventricular - was implanted. We achieve a successful result without complications. The patients was discharged without symptoms; the device interrogation showed good assessment of lead impedances, sensing thresholds, and capture thresholds.
 
 
 The mechanisms of tricuspid valve regurgitation following TLE are complex. There isn't a standardized best practice to approach this phenomenon. It's important after TLE to assess tricuspid valve structure and function with TTE in order to understand the incidence of underlying potential mechanism and how to prevent it. Complex venous anatomy could direct the choice toward epicardial leads implantation.
