Tracing the clues: QRS interval & ventricular dyssynchrony as early predictors of lead-related tricuspid regurgitation

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Abstract Introduction The pathophysiological mechanisms associated with the development of lead-related tricuspid regurgitation (TR) aren’t limited to mechanical interference with the tricuspid valve and subvalvular apparatus. The adverse ventricular remodeling induced by electromechanical intraventricular dyssynchrony plays an important role. Our study aimed to assess if the QRS interval post cardiac implantable electronic device (CIED) was an independent predictor for the development of lead-related TR. Methods Retrospective cohort study of patients with a de novo device implantation in the past 10 years. Baseline and post implantation electrocardiographic/echocardiographic parameters were obtained. Patients with TR worsening by at least 1 grade after CIED implantation were considered as lead-related TR (Group 1) and compared with a control group. We constructed a receiver operating characteristic (ROC) curve to identify the optimal QRS interval cutoff value to predict the development of lead-related TR. The area under the curve (AUC) was calculated to assess the diagnostic performance. Cardiovascular outcomes were assessed using Kaplan–Meier estimates and Cox proportional-hazards models. Results Our study included 108 pts, 47% female with a mean age 73±12 years. Single and dual-lead conventional pacemakers were the main implantable devices (45%). Regarding ECG data: Median baseline QRS was 123 vs 140ms in Group 1 and 2 respectively. Median QRS after CIED implantation was 158vs133ms Group 1 and 2 respectively. In the group of patients who developed lead related TR at follow-up we observed a statistically significant increase of QRS interval in the first ECG post CIED implantation (28.861ms, p<0.001). We found an optimal QRS cut-off value of 150ms with a sensitivity of 61% and specificity of 75% to predict the development of lead related TR. This value was an independent predictor with the development of severe TR after adjusting for multiple variables: age, TAPSE, ejection fraction, right atrium area, right ventricle dilation, atrial fibrillation, device (HR 3.935 CI 1.239-12.497, p=0.020). There was no statistically significant difference when analyzing the impact of QRS widening in cardiovascular outcomes. Conclusion In our study, we identified that the QRS interval with an optimal cut-off>150ms post-CIED implantation and the subsequent intraventricular dyssynchrony, was an independent risk factor for the development of severe TR.

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