New study findings reveal how leads from pacemakers and other cardiac implantable electronic devices (CIEDs) can contribute to or worsen tricuspid regurgitation (TR) by interfering with valve anatomy. Details of the retrospective multicenter study support the potential mechanistic insights and implications for patient management, whilst highlighting the complementary diagnostic role of computed tomography angiography (4D-CTA) in this context. “Despite renewed attention to tricuspid regurgitation… patients with TR and a cardiac implantable electronic device remain a clinically important subgroup that is poorly understood,” the authors noted. 4D-CTA’s role Led by João L. Cavalcante, MD, from Allina Health Minneapolis Heart Institute in Minnesota, the study found that in patients with CIED and severe TR, 4D-CTA helped identify the mechanism in 54% of the patients as CIED-related TR. Such patients typically have ≥4 leaflets and, despite similar annular size and larger anatomical regurgitant orifice area (AROA), mildly depressed RV ejection fraction and lower RV strain. The findings, which appear in JACC: Cardiovascular Interventions, also found these patients also had a longer median time since device implantation (7.1 years versus 3.7 years in the CIED-associated group) suggesting progressive valve disruption over time. Further insight Other findings of note identified a mild impairment of right ventricular (RV) function across all groups, but RV strain was worse in CIED-related cases (–15%) than in isolated TR (–18%). Over a median 1.6-year follow-up, mortality was initially higher in the CIED-related and CIED-associated groups, but adjusted analysis found no significant survival differences among the three. “4D-CTA provides important insights by identifying the mechanism in 54% of the patients as CIED-related TR,” said the research team, concluding that there was a potential role for imaging in guiding future management, including decisions about lead revision or extraction. Methodology The study involved 143 patients with severe TR, classified into three groups: CIED-related TR (where the lead interferes with valve function), CIED-associated TR (lead present but not directly causing regurgitation) and isolated TR (no CIED). For the entire cohort, median age was 83 (77-87) years, 59% were female, 87% had atrial fibrillation and 90% were in New York Heart Association (NYHA) functional class ≥II. CIED devices were most commonly pacemakers (40%) with a median time from CIED implantation to 4D-CTA of 5.4 years. All patients were evaluated using 4D-CTA, which enabled precise measurement of valve structure and right heart function. Source: Margonato D, Enriquez-Sarano M, Fukui M, et al. Lead-Related Tricuspid Regurgitation: Novel Insights Through the Lens of Computed Tomography. JACC Cardiovasc. Interv. 2025. (Article in Press). Image Credit: Acronym – stock.adobe.com