Q: All of  the following are risk factors of exacerbation of Tricuspid Regurgitation (TR) after insertion of  endocardial pacemaker/defibrillator?

A) Impingement of leads on a tricuspid valve leaflet
B) Tethering of  leads to the leaflet of tricuspid valves 
C) Perforation of  leads via leaflet of tricuspid valves
D) Entanglement of leads with subvalvular chordae 
E) Placement of  leads in a commissure


Answer:  E

Tricuspid Regurgitation continues to fumble cardiologists/physicians as any damage to tricuspid valve (TV) can be irreversibly catastrophic. Literature is ripe with debate on repair vs replacement of TV, as even a minor difference in clinical judgement can have a long-term trajectory effect. All of the above choices can increase or cause (TR) except choice E.

Actually one of the ways to avoid damage to TV is to secure placement of leads in a commissure, at a place outside the valve annulus, or replacement with epicardial leads.

References:

1. Al-Mohaissen MA, Chan KL. Prevalence and mechanism of tricuspid regurgitation following implantation of endocardial leads for pacemaker or cardioverter-defibrillator. J Am Soc Echocardiogr 2012; 25:245. 

2. Mazine A, Bouchard D, Moss E, et al. Transvalvular pacemaker leads increase the recurrence of regurgitation after tricuspid valve repair. Ann Thorac Surg 2013; 96:816. 

3. Molina JE, Roberts CL, Benditt DG. Long-term follow-up of permanent transvenous pacing systems preserved during tricuspid valve replacement. Ann Thorac Surg 2010; 89:318.