PPM or ICD Implantation Linked to Risk for Worsening Tricuspid Regurgitation

Risk for worsening tricuspid regurgitation is increased in patients with permanent pacemakers or implantable cardioverter-defibrillators.

Patients who have permanent pacemaker (PPM) or implantable cardioverter-defibrillator (ICD) implantation have an increased risk for worsening tricuspid regurgitation (TR), according to a study in Heart Rhythm.

A systematic review and meta-analysis was conducted to identify the overall incidence and patient-specific predictors of worsening TR after ICD or PPM implantation.

Researchers searched the CENTRAL, Medline, and Scopus databases from inception through January 2023. Eligible studies were randomized controlled trials and cohort studies that reported patients who received PPM or ICD implantation and had a follow-up echocardiogram to determine whether there was worsening TR by 1 degree or more (mild to moderate, or moderate to severe TR).

Log odds ratio was used to summarize group differences, and statistical significance of the between-group differences was determined with use of meta-analysis with a random-effect model.

Our analysis demonstrates that patients undergoing PPM or ICD implantation are at an increased risk of worsening TR.

The analysis included 29 studies (8 prospective, 21 retrospective) with 66,590 participants (60% men; mean age, 68 years).

In 2 studies (59,613 participants) that compared patients who had a device implantation with control groups, patients with device implantation (n=1008) were significantly more likely to have worsening TR vs control individuals (n=58,605) (odds ratio [OR], 3.18; 95% CI, 1.58-6.39; P <.01). In analysis of 28 studies with 7777 patients, the pooled incidence of 1 degree or more worsening of TR post-implantation was 23%.

Worsening TR after device implantation significantly increased mortality (hazard ratio, 1.42; 95% CI, 1.05-1.92; P =.02). In addition, greater right atrial area (OR, 1.11; 95% CI, 1.06-1.17; P <.01) was significantly associated with an increased risk of worsening TR postimplantation, and men (OR, 0.74; 95% CI, 0.61-0.91; P <.01) were less likely to have this complication vs women.

No statistically significant difference was observed between the ICD and PPM groups for TR (OR, 1.12; 95% CI, 0.57-2.18; P =.71).

Right ventricular dysfunction (OR, 0.99; 95% CI, 0.98-1.01; P =.47), baseline pulmonary hypertension (OR, 1.03; 95% CI, 0.99-1.07; P =.12), baseline mitral regurgitation (OR, 1.75; 95% CI, 0.74-4.1; P =.20), left ventricular ejection fraction (OR, 0.99; 95% CI, 0.94-1.04; P =.69), baseline atrial fibrillation (OR, 1.94; 95% CI, 0.67-5.66; P =.22), and increasing age (OR, 1.0; 95% CI, 0.98-1.01; P =.75) were not associated with worsening TR after device implantation.

Among several study limitations, TR after device implantation has an uncertain etiology and significant heterogeneity was observed. In addition, individual patient-level data are not available, most participants are from single-center and retrospective studies, and the etiology of mortality was not specified in the included studies.

“Our analysis demonstrates that patients undergoing PPM or ICD implantation are at an increased risk of worsening TR,” the researchers wrote. “Most important, this complication significantly increases mortality.”


Alnaimat S, Doyle M, Krishnan K, Biederman RWW. Worsening tricuspid regurgitation associated with permanent pacemaker and implantable cardioverter-defibrillator implantation: a systematic review and meta-analysis of over 66,000 subjects. Heart Rhythm. Published online July 25, 2023. doi: 10.1016/j.hrthm.2023.07.064