Managing Implanted Cardiac Electronic Devices in Patients With Severe Tricuspid Regurgitation: JACC State-of-the-Art Review.

Orthotopic transcatheter tricuspid valve replacement (TTVR) devices have been shown to be highly effective in reducing tricuspid regurgitation (TR), and interest in this therapy is growing with the recent commercial approval of the first orthotopic TTVR. Recent TTVR studies report preexisting cardiac implantable electronic device (CIED) transvalvular leads in ∼35% of patients, with entrapment during valve implantation. Concerns have been raised regarding the safety of entrapping leads and counterbalanced against the risks of transvenous lead extraction (TLE) when indicated. This Heart Valve Collaboratory consensus document attempts to define the patient population with CIED lead-associated or lead-induced TR, describe the risks of lead entrapment during TTVR, delineate the risks and benefits of TLE in this setting, and develop a management algorithm for patients considered for TTVR. An electrophysiologist experienced in CIED management should be part of the multidisciplinary heart team and involved in shared decision making.

Pivotal trials of cardiac resynchronization therapy: evolution to therapy in mild heart failure.

Cardiac resynchronization therapy (CRT) has traditionally been reserved for patients with left ventricular (LV) dysfunction in the setting of advanced heart failure. Early clinical trials clearly demonstrated reverse ventricular remodeling and clinical benefits following CRT in this population. More recently, with the publication of the REVERSE, MADIT-CRT, and RAFT trials, the benefits of CRT have been demonstrated in patients with LV dysfunction and mild heart failure calling into question the optimal timing for biventricular pacemaker implantation. With the expanded indications for CRT arising from these studies, significant questions remain specifically with regards to the economic impact on health care systems and to the added risk of future morbidity due to device infection and malfunction.