Endocardial Device Leads in Patients with Patent Foramen Ovale: Echocardiographic Correlates of Stroke/TIA and Mortality

Abstract

Background Echocardiographically detected patent foramen ovale (PFO) has been associated with stroke/transient ischemic attack (TIA) in patients with cardiac implantable electronic devices (CIED). We sought to evaluate the relationship between echocardiographic characteristics and risk of stroke/TIA and mortality in CIED patients with PFO. Methods In 6086 device patients, PFO was detected in 319 patients. A baseline echocardiogram was present in 250 patients, with 186 having a follow-up echocardiogram. Results Out of 250 patients with a baseline echocardiogram, 9.6% (n=24) had a stroke/TIA during mean follow-up of 5.3 ± 3.1 years; and 42% (n=105) died over 7.1 ± 3.7 years. Atrial septal aneurysm (ASA), prominent Eustachian valve (EV), visible shunting across PFO, baseline or change in estimated right ventricular systolic pressure (RVSP)/tricuspid regurgitation (TR) or maximum RVSP were not associated with post-implant stroke/TIA (p>0.05). An exploratory multivariate analysis using time-dependent cox models showed increased hazard of death in patients with increase in TR ≥2 grades (HR 1.780, 95% CI 1.447 – 2.189, p<0.0001) or increase in RVSP by >10 mmHg (HR 2.018, 95% CI 1.593 – 2.556, p<0.0001) or maximum RVSP in follow up (HR 1.432, 95% CI 1.351 – 1.516, p<0.0001). A significant increase (p-value <0.001) in TR was also noted during follow up. Conclusions In patients with CIED and PFO, structural and hemodynamic echocardiographic markers did not predict future stroke/TIA. However, a significantly higher TR or RVSP was associated with higher mortality.

Real‐world experience with leadless cardiac pacing

“…Transvenous lead implantation can result in TR due to mechanical interaction with the tricuspid valve apparatus, or annular dilation from heart failure . Recent data suggest increased risk of mortality among pacemaker patients with greater severity of tricuspid regurgitation . Leadless pacemakers may be associated with lower risk of worsening TR, since there is none to minimal interaction of the device with the tricuspid valve apparatus.…”