Transesophageal echocardiographic evaluation of tricuspid valve regurgitation during pacemaker and implantable cardioverter defibrillator lead extraction

Chronically implanted ventricular pacing and defibrillator (ICD) leads can adhere to the tricuspid valve. This study examined the effect of lead extraction, and laser sheath extraction in particular, on tricuspid valve regurgitation. Lead extraction was first tried with traction using limited force followed by a laser sheath if not successful. Tricuspid valve regurgitation before and after extraction was evaluated with transesophageal echocardiography and graded from 0 (none) to 4 (severe). A change in regurgitation was considered clinically relevant if it increased with two grades or more and resulted in at least grade 3 regurgitation. Fifty ventricular leads were extracted in 43 consecutive patients, including 14 ICD leads. In 20 patients (group I) leads were removed without a (laser) sheath crossing the tricuspid valve, in 23 patients (group II) leads were extracted with lasing across the valve. The mean time from implant was 43 +/- 43 months and 99 +/- 78 months, respectively, (P = 0.007). Tricuspid regurgitation increased in five (12%) patients. In group I only in one patient the laser failed proximal of the valve and forceful traction was subsequently used, and in group II this occurred in four (17%) patients. This difference did not reach statistical significance even excluding the patient from group I (P = 0.111). The increase of tricuspid regurgitation cautions against indiscriminate extraction of superfluous leads. There is a trend that when tools like a laser sheath are necessary the chance of tricuspid valve damage increases.