title: 3D echocardiographic location of implantable device leads and mechanism of associated tricuspid regurgitation.
abstract: OBJECTIVE
  This study sought to: 1) determine the feasibility of using 3-dimensional transthoracic echocardiography (3D TTE) in patients with implantable cardiac resynchronization devices, pacemakers, and defibrillators to visualize the device leads in the right heart and their position relative to the tricuspid valve leaflets; 2) determine the prevalence of different lead positions; and 3) study the relationship between lead location and tricuspid regurgitation (TR) severity.
  
  
  BACKGROUND
  Pacemaker, defibrillator, and cardiac resynchronization device implantation is currently guided by fluoroscopy, not allowing targeted lead positioning relative to the tricuspid valve leaflets. These leads have been reported to cause TR of variable degrees, but echocardiography is not routinely used to elucidate the mechanisms of lead interference with tricuspid valve leaflets in individual patients.
  
  
  METHODS
  3D TTE full-volume images of the right ventricle and/or zoomed images of the tricuspid valve were obtained in 121 patients with implanted devices. Images were viewed offline to determine the position of the device-lead relative to the tricuspid valve leaflets. Severity of TR was estimated on the basis of vena contracta measurements.
  
  
  RESULTS
  3D TTE clearly depicted lead position in 90% of patients. The right ventricular lead was impinging on either the posterior (20%) or septal (23%) leaflet or was not interfering with leaflet motion (53%) when positioned near the posteroseptal commissure or in the central portion of the tricuspid valve orifice. In the remaining patients, leads were impinging on the anterior leaflet (4%) or positioned in either the anteroposterior or anteroseptal commissure (3%). Leads interfering with normal leaflet mobility were associated with more TR than nonimpinging leads (vena contracta: median 0.62 cm [1st and 3rd quartiles: 0.51, 0.84 cm] vs. 0.27 cm [1st and 3rd quartiles: 0.00, 0.48 cm]; p < 0.001).
  
  
  CONCLUSIONS
  3D TTE showed a clear association between device lead position and TR. To minimize TR induced by device-leads, 3D TTE guidance should be considered for placement in a commissural position.
authors.affiliation: Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois.
authors.forename: Anuj
authors.initials: A
authors.lastname: Mediratta
authors.affiliation: Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois.
authors.forename: Karima
authors.initials: K
authors.lastname: Addetia
authors.affiliation: Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois.
authors.forename: Megan
authors.initials: M
authors.lastname: Yamat
authors.affiliation: Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois.
authors.forename: Joshua D
authors.initials: JD
authors.lastname: Moss
authors.affiliation: Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois.
authors.forename: Hemal M
authors.initials: HM
authors.lastname: Nayak
authors.affiliation: Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois.
authors.forename: Martin C
authors.initials: MC
authors.lastname: Burke
authors.affiliation: Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois.
authors.forename: Lynn
authors.initials: L
authors.lastname: Weinert
authors.affiliation: Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois.
authors.forename: Francesco
authors.initials: F
authors.lastname: Maffessanti
authors.affiliation: Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois.
authors.forename: Valluvan
authors.initials: V
authors.lastname: Jeevanandam
authors.affiliation: Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois.
authors.forename: Victor
authors.initials: V
authors.lastname: Mor-Avi
authors.affiliation: Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois. Electronic address: rlang@medicine.bsd.uchicago.edu.
authors.forename: Roberto M
authors.initials: RM
authors.lastname: Lang
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D058409:Cardiac Resynchronization Therapy Devices / Q000009:adverse effects; D017147:Defibrillators, Implantable / Q000009:adverse effects*; D018618:Echocardiography, Doppler, Color; D019560:Echocardiography, Three-Dimensional; D017548:Echocardiography, Transesophageal; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010138:Pacemaker, Artificial / Q000009:adverse effects*; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D014261:Tricuspid Valve / Q000000981:diagnostic imaging* / Q000503:physiopathology; D014262:Tricuspid Valve Insufficiency / Q000000981:diagnostic imaging* / Q000209:etiology / Q000503:physiopathology
keywords: 3-dimensional echocardiography; intracardiac defibrillator; pacemaker; tricuspid regurgitation; tricuspid valve