In our "Quick Dive" series, the authors of publications from medical societies summarise the most important information and results of the respective publication. This time we dive into:
Quick Dive: Management of patients with transvalvular right ventricular leads undergoing TTVI
Management of patients with transvalvular right ventricular leads undergoing transcatheter tricuspid valve interventions
A Scientific Statement of the European Heart Rhythm Association and the European Association of Percutaneous Cardiovascular Interventions of the ESC endorsed by the Heart Rhythm Society, the Asian Pacific Heart Rhythm Society and the Canadian Heart Rhythm Society
31 March 2025 | Written by: Jean-Claude Deharo, Julien Dreyfus, Maria-Grazia Bongiorni, Haran Burri, Pascal Defaye, Michael Glikson, Nigel Lever, Antonio Mangieri, Blandine Mondésert, Jens Cosedis Nielsen, Maully Shah, Christoph Thomas Starck, Archana Rao, Christophe Leclercq, Fabien Praz, Sergio Richter, Nicolas Amabile, Alexander Breitenstein, Óscar Cano, Karol Čurila, Jamie Manlucu, Robert D Schaller, Hung-Fat Tse, Christian Veltmann, Zachary Whinnett
By:
Martin Nölke
HERZMEDIZIN editorial team
2025-07-25
Image source (image above): vovan / Shutterstock.com (edited)
5 questions for the author
Prof. Jean-Claude Deharo, Aix-Marseille University, Marseille, France
What is the reason for and aim of the publication?
Up to one third of patients referred for transcatheter tricuspid valve intervention (TTVI) have a transvalvular pacemaker or implantable cardioverter-defibrillator lead in place. Both the electrophysiology and interventional cardiology communities have been alerted to the complexity of decision making in this situation due to potential interactions between the leads and the TTVI material, including the risk of jailing or damage to the leads. This document, commissioned by the European Heart Rhythm Association (EHRA) and the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC, reviews the scientific evidence to inform Heart Team discussions on the management of patients with a PPM or ICD who are scheduled for or have undergone TTVI.
What are the most important take-home messages?
- A significant proportion of candidates for transcatheter tricuspid valve interventions (TTVI) have transvenous cardiac implantable electronic device (CIED) leads.
- Scientific evidence concerning TTVI in patients with CIED leads is scarce and primarily derived from observational studies or first-in-human reports.
- Experience with lead jailing during TTVI is limited; however, lead failure or dislodgement have been reported. Lead-jailing is a real concern during TTVI: it increases the risk of lead dysfunction or makes future extraction impossible.
- Transvenous lead extraction to prepare for TTVI and valve-sparing CIED implantation techniques are potential options. Heart team discussions and patient engagement are crucial when making these decisions.
- There is a strong need for increased evidence regarding CIED patients who undergo TTVI.
Fig.: Proposed algorithm for the management of TTVI candidates with symptomatic severe TR and a CIED lead crossing the TV. *Perform device interrogation and record underlying heart rhythm, paced/sensed event counters, arrhythmia history, battery and lead information (see also Table 6). **Red/orange flag(s) for lead jailing? PM dependency, ICD with previous therapy, multiple CIED leads crossing the TV, previous CIED infection, multiple risk factors for CIED infection, high lead tension (low slack) and/or leaflet impingement (in case of direct annuloplasty) (see also Figure 5).
© 2025 the European Society of Cardiology. Europace (2025) 27, euaf061 https://doi.org/10.1093/europace/euaf061.
What are challenges in practical implementation – and possible solutions?
- The fact that electrophysiology and interventional cardiology teams often work independently may impede the practical implementation of this consensus document.
- Potential procedure-related risks of lead extraction remains a significant barrier; this necessitates thorough multidisciplinary planning and risk stratification.
- Lack of standardization in clinical practice can impede optimal patient management, reinforcing the relevance of Heart Team discussions guided by proposed algorithms and the identification of red and orange flags.
Which issues still need to be tackled, that are not yet addressed by the paper?
Long-term outcomes of lead jailing are largely unknown.
What further developments on the topic are emerging?
Clinical data is being increasingly gathered on patients with transvalvular cardiac implantable electronic device (CIED) leads undergoing transcatheter tricuspid valve interventions (TTVI), with the aim of better understanding procedural outcomes, lead-related complications, and long-term prognostic implications in this growing patient population.
Continue to the publication:
Reference: Deharo JC, Dreyfus J, Bongiorni MG et al. Management of patients with transvalvular right ventricular leads undergoing transcatheter tricuspid valve interventions: a scientific statement of the European Heart Rhythm Association and the European Association of Percutaneous Cardiovascular Interventions of the ESC endorsed by the Heart Rhythm Society, the Asian Pacific Heart Rhythm Society and the Canadian Heart Rhythm Society. Europace. 2025 May 7;27(5):euaf061. doi: 10.1093/europace/euaf061.
ESC Document types
Document types published by the ESC, Associations, Councils, Working Groups, and ESC Committees (according to the ESC Scientific Documents Policy):
ESC Clinical Practice Guidelines present the official ESC position on key topics in cardiovascular medicine. They are based on the assessment of published evidence and consensus by an independent group of experts. The documents include standardized, graded recommendations for clinical practice and indicate the level of supporting evidence.
ESC Pocket Guidelines provide a compact, practice-oriented summary of the full guideline, including all recommendation classes and levels of evidence.
Clinical Consensus Statements provide guidance for clinical management on topics not covered or not covered in sufficient detail in existing or upcoming ESC Clinical Practice Guidelines by evaluating scientific evidence or exploring expert consensus in a structured way.
Scientific Consensus Statements interpret scientific evidence and provide a summary position on the topic without specific advice for clinical practice.
Statements outline and convey the organisation’s position or policy on non-medical issues such as education, advocacy and ethical considerations.
ESC Quality Indicators enable healthcare providers to develop valid and feasible metrics to measure and improve the quality of cardiovascular care and describe, in a specific clinical situation, aspects of the process of care that are recommended (or not recommended) to be performed.