Performance of Pacemaker Leads in Alternative Lead Positions after Tricuspid Valve Replacement

Objectives: Bradycardic arrhythmias requiring pacemaker implantation are still a common complication after tricuspid valve replacement (TVR). Leaving the pacemaker lead in an extravalvular position may help to prevent prosthesis dysfunction. This study was aimed to examine the midterm outcome of paravalvular or single coronary sinus leads with respect to lead survival and prosthesis dysfunction in patients after TVR.

Methods: A retrospective case control study of patients with TVR and necessity for ventricular pacing was conducted. Consecutive patients from the database of the Leipzig’s Heart Center between 1995 and 2018 were included. Data of the paravalvular lead group (PVG) and coronary sinus lead group (CSG) were compared with a control group with conventional transvalvular lead positioning (TVG). Data are reported as median (min–max) or n (%).

Result: Eighty patients with TVR and cardiac pacemaker (TVG, n = 13; PVG, n = 40; and CSG, n = 27) were included. The midterm follow-up was 2.8 years and mean age was 66 years. The rate of lead revision was lower in PVG but without significance (p = 0.286). The CSG demonstrated significantly higher pacing thresholds at follow-up (1.4 V/0.8 ms) than TVG (0.5 V/0.4 ms), (p = 0.004). However, deterioration of threshold amplitudes during follow-up was similar in CSG and PVG compared with controls. Function of TV prosthesis at follow-up regarding development of stenosis or regurgitation showed a similarity between PVG and CSG compared with controls (regurgitation TVG, p = 0.692; CSG, p = 1; stenosis TVG, p = 0.586; CSG, 0.69). Overall, the rate of newly diagnosed endocarditis at follow-up was low ([Table 1]).

Table 1 Events during follow-up per patient group

Follow-up	TVG (n = 13)	PVG (n = 40)	p-Value	CSG (n = 27)	p-Value
Increased PM threshold	1 (7.7)	3 (7.5)	1	2 (7.4)	1
PM lead revision	2 (15.4)	1 (2.5)	0.145	2 (7.4)	0.584
Increased TV pressure gradient	2 (15.4)	3 (7.5)	0.586	7 (25.9)	0.69
Increased TV regurgitation	3 (23.1)	7 (17.5)	0.692	5 (18.5)	1
New paravalvular leak	0 (0.0)	1 (2.5)	1	0 (0.0)	1

Conclusion: Paravalvular positioning of pacemaker leads seems to represent a reasonable alternative to the conventional transvalvular lead positioning with regard to function of the lead and tricuspid valve prosthesis.