Quick Dive: Management of patients with transvalvular right ventricular leads undergoing TTVI

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?

1. A significant proportion of candidates for transcatheter tricuspid valve interventions (TTVI) have transvenous cardiac implantable electronic device (CIED) leads.
2. Scientific evidence concerning TTVI in patients with CIED leads is scarce and primarily derived from observational studies or first-in-human reports.
3. 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.
4. 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.
5. There is a strong need for increased evidence regarding CIED patients who undergo TTVI.
   

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.

Scientific statement: "Management of patients with transvalvular right ventricular leads undergoing transcatheter tricuspid valve interventions"

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.

Document types published by the ESC, Associations, Councils, Working Groups, and ESC Committees (according to the ESC Scientific Documents Policy):