April 21, 2026
Advancements in percutaneous interventions are offering alternatives for managing tricuspid regurgitation for patients who may be at higher risk of surgery. The increase in transcatheter therapies has created an urgent need for data on patients with preexisting cardiac implantable electronic devices (CIEDs). What happens to the pacemaker or defibrillator leads after transcatheter tricuspid valve replacement (TTVR)?
Mayo Clinic cardiovascular researchers sought to understand the potential lead-related concerns. Their retrospective observational study was published in EP Europace. The comprehensive analysis evaluated the impact of TTVR therapy on device-lead function in patients undergoing TTVR therapy. The study consisted of 32 patients with preexisting CIEDs. The mean age was 79 and 59% of patients were female.
Leaving in the leads
Today, many patients with tricuspid regurgitation have CIEDs, raising concerns about possible lead-related complications. "Our study addresses this critical and increasingly common challenge in structural heart disease and electrophysiology. It offers one of the first detailed, real-world looks at how preexisting CIED leads perform after they are left in place or 'jailed' during transcatheter tricuspid valve replacement therapy," says Alan M. Sugrue, M.B., B.Ch., B.A.O., a cardiac electrophysiologist at Mayo Clinic in Rochester, Minnesota, and senior author of the study. "There was a clear need for this work because prior TTVR studies established the efficacy of the therapy for tricuspid regurgitation, but they did not provide detailed lead-function data. For patients undergoing TTVR with preexisting CIEDs, this creates a genuine dilemma of 'jailing' versus extraction."
While jailing the lead avoids extraction risk, it raises concerns about:
- Mechanical compression.
- Sensing changes.
- Insulation damage.
- Long-term lead integrity.
"It's common for patients to already have leads from a pacemaker or defibrillator crossing the valve. Extraction before TTVR is not a simple solution, because it can carry meaningful procedural risk in patients who may be older with long-standing leads and may be dependent on these leads. This study was designed to fill that evidence gap and provide practical guidance for decisions that must be made regularly without much real world data," says Kimberly A. Holst, M.D., a cardiothoracic surgeon and structural interventional cardiologist at Mayo Clinic in Rochester, Minnesota.
Study highlights
The researchers found that lead-related electrical abnormalities occurred in nearly one-third of patients after TTVR therapy.
- The most common issue was a change in right ventricular sensing. In many patients, it was an isolated finding that could be managed conservatively without lead revision.
- In 13% of patients the findings showed lead insulation breach manifesting as noise oversensing with or without impedance drop. One patient (3%) required lead revision.
- Most abnormalities emerged early within the first 90 days, which supports the need for close surveillance soon after the procedure.
- Neither lead slack nor anatomic lead position reliably predicted which patients would develop problems.
Two things stood out that the researchers did not expect. "The 13% rate of insulation-breach finding was higher than we had anticipated. On the positive side, it was reassuring to see that most sensing changes were isolated and could be handled without major intervention," Dr. Sugrue says. "We were also surprised that neither lead slack nor commissural position helped predict dysfunction. We hoped that imaging might give us clearer guidance, but the interaction between the valve frame and the lead during deployment appeared more complex than we realized."
Next steps
Future studies need to focus on determining the strategies for managing device-lead interactions in patients and on refining implantation techniques.
"Our data show that jailing leads is not risk-free and careful follow-up is important," Dr. Sugrue says. "Better preprocedural risk stratification tools are also needed, even though current imaging parameters did not prove predictive in this cohort." The data can help when informing patients about whether to jail or extract leads before the procedure.
Questions remain and long-term studies are needed to determine:
- If early sensing changes progress.
- When jailed leads could be safely extracted later without affecting the prosthesis.
- How often subclinical impedance trends become clinically relevant.
Prospective registries and multicenter collaborative efforts comparing different lead management strategies will be essential. They should evaluate:
- Extraction versus jailing.
- Pre-TTVR extraction with reimplantation.
- Alternative pacing approaches such as leadless systems or coronary sinus-based options.
Mayo Clinic specialists continue to collaborate on new research and innovative solutions for patients with complex cardiovascular disease.
For more information
Abbasi M, et al. Device-lead abnormalities and function after transcatheter tricuspid valve replacement. EP Europace. 2025;27:euaf219.
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