INTERVENTIONAL FLASHLIGHT

DOI: 10.4244/EIJ-D-17-00693

Transcatheter edge-to-edge repair of lead-associated tricuspid regurgitation

Neil P. Fam*, MD, MSc; Edwin C. Ho, MD; Naveed Ahmed, MD, DM; Kim A. Connelly, MD, PhD

A 70-year-old woman presented with heart failure. Past history included coronary disease with previous coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), left ventricular (LV) dysfunction with ejection fraction (EF) 30%, previous implantable cardioverter defibrillator (ICD) and atrial fibrillation. The patient had persistent NYHA Class III dyspnoea, fatigue and peripheral oedema despite medical therapy and cardiac resynchronisation therapy (CRT) upgrade one year prior. Echocardiography demonstrated severe secondary mitral regurgitation (MR) (Panel A) and severe secondary tricuspid regurgitation (TR) (Panel B) due to ICD lead impingement on the septal leaflet and annular dilatation (Panel C, Moving image 1). After Heart Team review, combined transcatheter mitral and tricuspid repair with the MitraClip (Abbott Vascular, Santa Clara, CA, USA) was planned.

A single MitraClip was deployed at A2-P2 resulting in mild MR (Panel D) with a mean gradient of 2 mmHg. After withdrawing the guide catheter into the right atrium, the clip delivery system was navigated perpendicular to the anterior and septal leaflets using 3D transoesophageal echo and fluoroscopy (Panel C, Moving image 2). The anterior and septal leaflets were treated with two clips, starting at the commissure and carefully avoiding the lead, resulting in mild TR (Panel E, Panel F, Moving image 3) with a mean gradient of 2 mmHg. The patient was discharged home the next day. At one-month follow-up, she reported improved symptoms and functional capacity. Baseline 6-minute walk test increased from 260 to 400 m, and NT-BNP decreased from 4,394 to 3,572 ng/L. Repeat echocardiography was unchanged.

Tricuspid regurgitation (TR) is an increasingly recognised complication of pacemaker and defibrillator lead insertion, and carries a poor prognosis1,2. The septal and posterior leaflets are most frequently involved, with TR resulting from lead perforation, impingement or adherence to the leaflets, often with associated tethering. Surgical treatment usually involves lead repositioning and leaflet repair combined with annuloplasty, but has significant associated morbidity and mortality. Of the currently available transcatheter tricuspid repair devices, only the MitraClip can directly address lead-induced leaflet tethering3.

In this report, we demonstrate the feasibility of MitraClip for lead-associated TR, treating the anterior and septal leaflets with significant and sustained TR reduction. Given that TR caused by device leads is often focal, it would appear ideally suited for edge-to-edge repair with the MitraClip. In our case, TR was due to both lead-induced septal leaflet tethering and annular dilatation, and TR reduction was achieved by improved coaptation between the anterior and septal leaflets after implantation of two clips.

Comprehensive echo assessment to determine the mechanism of TR is essential prior to considering intervention, and operators should avoid placing clips too close to device leads to prevent leaflet trauma. In future, combined transcatheter tricuspid edge-to-edge repair and annuloplasty may provide the best long-term outcomes, reproducing the surgical standard.

Conflict of interest statement

The authors have no conflicts of interest to declare.

Supplementary data

Moving image 1. Preprocedural 3D TEE demonstrating impingement of the septal leaflet by the ICD lead.

Moving image 2. Intraprocedural 3D TEE of guide navigation in the right atrium.

Moving image 3. Post-procedural 3D TEE after implantation of clips between anterior and septal leaflets.

Supplementary data

To read the full content of this article, please download the PDF.

Preprocedural 3D TEE demonstrating impingement of the septal leaflet by the ICD lead.

Intraprocedural 3D TEE of guide navigation in the right atrium.

Post-procedural 3D TEE

Volume 13 Number 10
Nov 20, 2017
Volume 13 Number 10
View full issue


Key metrics

Suggested by Cory

TRICUSPID VALVE INTERVENTIONS

10.4244/EIJV12SYA29 Sep 18, 2016
Transcatheter interventions for tricuspid regurgitation: MitraClip
Schueler R et al
free

SPECIAL REPORT

10.4244/EIJV11I13A296 Apr 20, 2016
First transfemoral percutaneous edge-to-edge repair of the tricuspid valve using the MitraClip system
Wengenmayer T et al
free

EXPERT REVIEW

10.4244/EIJ-D-17-00571 Sep 24, 2017
The big parade: emerging percutaneous mitral and tricuspid valve devices
Natarajan D et al
free

Image – Interventional flashlight

10.4244/EIJ-D-20-01295 Aug 6, 2021
Transcatheter tricuspid valve repair with the modified TriClip/MitraClip G4 system
Fam N et al
free

Editorial

10.4244/EIJ-E-25-00006 Mar 3, 2025
Tricuspid annuloplasty: a piece of the puzzle or the whole picture?
Nickenig G and Vogelhuber J
free

10.4244/EIJV15I10A159 Nov 15, 2019
The five Ws of transcatheter tricuspid valve repair: Who, What, When, Where, and Why
Williams A et al
free

INTERVENTIONAL FLASHLIGHT

10.4244/EIJ-D-18-00672 Oct 12, 2018
Intracardiac echocardiography for guidance of transcatheter tricuspid edge-to-edge repair
Fam N et al
free
Trending articles
309.93

State-of-the-Art Review

10.4244/EIJ-D-21-00695 Nov 19, 2021
Transcatheter treatment for tricuspid valve disease
Praz F et al
free
166.7

Expert review

10.4244/EIJ-D-21-00690 May 15, 2022
Crush techniques for percutaneous coronary intervention of bifurcation lesions
Moroni F et al
free
92.2

State-of-the-Art Review

10.4244/EIJ-D-20-01296 Aug 27, 2021
Management of cardiogenic shock
Thiele H et al
free
76

State-of-the-Art

10.4244/EIJ-D-23-00840 Sep 2, 2024
Aortic regurgitation: from mechanisms to management
Baumbach A et al
free
72.85

State-of-the-Art

10.4244/EIJ-D-24-00386 Feb 3, 2025
Mechanical circulatory support for complex, high-risk percutaneous coronary intervention
Ferro E et al
free
58.3

Clinical research

10.4244/EIJ-D-23-00344 Sep 18, 2023
Clinical outcomes of TAVI with the Myval balloon-expandable valve for non-calcified aortic regurgitation
Sanchez-Luna JP et al
free
56.65

Clinical research

10.4244/EIJ-D-20-01155 Oct 20, 2021
A deep learning algorithm for detecting acute myocardial infarction
Liu W et al
free
33.9

CLINICAL RESEARCH

10.4244/EIJ-D-17-00381 Oct 11, 2017
Stent malapposition and the risk of stent thrombosis: mechanistic insights from an in vitro model
Foin N et al
free
33.65

State-of-the-Art

10.4244/EIJ-D-23-00606 Jan 1, 2024
Targeting inflammation in atherosclerosis: overview, strategy and directions
Waksman R et al
free
X

The Official Journal of EuroPCR and the European Association of Percutaneous Cardiovascular Interventions (EAPCI)

EuroPCR EAPCI
PCR ESC
Impact factor: 7.6
2023 Journal Citation Reports®
Science Edition (Clarivate Analytics, 2024)
Online ISSN 1969-6213 - Print ISSN 1774-024X
© 2005-2025 Europa Group - All rights reserved