2nd Clinical Cardiology Department, Swietokrzyskie Cardiology Center, Kielce, Poland.
Cardiol J. 2013;20(4):402-10. doi: 10.5603/CJ.2013.0099.
Lead-dependent tricuspid dysfunction (LDTD) is one of important complications in patients with cardiac implantable electronic devices. However, this phenomenon is probably underestimated because of an improper interpretation of its clinical symptoms. The aim of this study was to identify LDTD mechanisms and management in patients referred for transvenous lead extraction (TLE) due to lead-dependent complications.
Data of 940 patients undergoing TLE in a single center from 2009 to 2011 were assessed and 24 patients with LDTD were identifi ed. The general indications for TLE, pacing system types and lead dwell time in both study groups were comparatively analyzed. The radiological and clinical effi cacy of TLE procedure was also assessed in both groups with precision estimation of clinical status patients with LDTD (before and after TLE). Additionally, mechanisms, concomitant lead-dependent complications and degree (severity) of LDTD before and after the procedure were evaluated. Telephone follow-up of LDTD patients was performed at the mean time 1.5 years after TLE/replacement procedure.
The main indications for TLE in both groups were similar (apart from isolated LDTD in 45.83% patients from group I). Patients with LDTD had more complex pacing systems with more leads (2.04 in the LDTD group vs. 1.69 in the control group; p = 0.04). There were more unnecessary loops of lead in LDTD patients than in the control group (41.7% vs. 5.24%; p = 0.001). There were no signifi cant differences in average time from implantation to extraction and the number of preceding procedures. Signifi cant tricuspid regurgitation (TR-grade III-IV) was found in 96% of LDTD patients, whereas stenosis with regurgitation in 4%. The 10% frequency of severe TR (not lead dependent) in the control group patients was observed. The main mechanism of LDTD was abnormal leafl et coaptation caused by: loop of the lead (42%), septal leafl et pulled toward the interventricular septum (37%) or too intensive lead impingement of the leafl ets (21%). LDTD patients were treated with TLE and reimplantation of the lead to the right ventricle (87.5%) or to the cardiac vein (4.2%), or surgery procedure with epicardial lead placement following ineffective TLE (8.3%). The radiological and clinical effi cacy of TLE procedure was very high and comparable between the groups I and II (91.7% vs. 94.2%; p = 0.6 and 100% vs. 98.4%; p = 0.46, respectively). Repeated echocardiography showed reduced severity of tricuspid valve dysfunction in 62.5% of LDTD patients. The follow- -up interview confi rmed clinical improvement in 75% of patients (further improvement after cardiosurgery in 2 patients was observed).
LDTD is a diagnostic and therapeutic challenge. The main reason for LDTD was abnormal leafl et coaptation caused by lead loop presence, or propping, or impingement the leafl ets by the lead. Probably, TLE with lead reimplantation is a safe and effective option in LDTD management. An alternative option is TLE with omitted tricuspid valve reimplantation. Cardiac surgery with epicardial lead placement should be reserved for patients with ineffective previous procedures.
心脏植入式电子设备患者中，铅依赖性三尖瓣功能障碍（LDTD）是重要并发症之一。然而，由于对其临床症状的不当解读，这种现象可能被低估了。本研究旨在确定因导线相关并发症而接受经静脉导线拔除（TLE）的患者中 LDTD 的机制和处理方法。
评估了 2009 年至 2011 年在一家中心接受 TLE 的 940 名患者的数据，并确定了 24 名 LDTD 患者。比较了两组患者 TLE 的一般适应证、起搏系统类型和导线留置时间。还评估了两组 TLE 手术的放射学和临床疗效，并对 LDTD 患者的临床状态进行了精确估计（TLE 前后）。此外，还评估了手术前后 LDTD 的机制、同时存在的导线依赖性并发症和严重程度（严重程度）。在 TLE/置换手术后 1.5 年，对 LDTD 患者进行了电话随访。
两组患者的主要 TLE 适应证相似（第 I 组中有 45.83%的患者为孤立性 LDTD）。LDTD 患者的起搏系统更复杂，导线更多（LDTD 组 2.04 根，对照组 1.69 根；p=0.04）。LDTD 患者的导线中存在更多不必要的环路（41.7%比对照组的 5.24%；p=0.001）。从植入到拔除的平均时间和先前手术的数量在两组之间没有显著差异。96%的 LDTD 患者存在显著的三尖瓣反流（TR 分级 III-IV），而 4%的患者存在狭窄伴反流。在对照组患者中，观察到 10%的严重 TR（非导线依赖性）频率。LDTD 的主要机制是异常瓣叶对合，原因是：导线的环（42%）、隔瓣叶被拉向室间隔（37%）或导线对瓣叶的过度撞击（21%）。LDTD 患者接受 TLE 治疗，将导线重新植入右心室（87.5%）或心静脉（4.2%），或在 TLE 无效时进行心脏手术，在心外膜放置导线（8.3%）。TLE 手术的放射学和临床疗效非常高，两组之间无显著差异（第 I 组为 91.7%比 94.2%；p=0.6；第 II 组为 100%比 98.4%；p=0.46）。重复超声心动图显示 62.5%的 LDTD 患者三尖瓣功能障碍严重程度降低。随访访谈证实 75%的患者临床状况改善（2 例患者在心脏手术后进一步改善）。
LDTD 是一个诊断和治疗上的挑战。LDTD 的主要原因是导线环的存在、导线的支撑或撞击导致瓣叶异常对合。可能，TLE 联合导线再植入是 LDTD 管理的一种安全有效的选择。另一种选择是 TLE 联合三尖瓣再植入的省略。对于先前治疗无效的患者，应保留心脏手术并在心外膜放置导线。
