Worsening tricuspid regurgitation associated with permanent pacemaker and implantable cardioverter-defibrillator implantation: A systematic review and meta-analysis of more than 66,000 subjects

Background Worsening TR following either PPM or ICD implantation is an emerging clinical challenge. Early recognition of this entity is essential in guiding treatment. Objective This meta-analysis was designed to identify overall incidence and patient-specific predictors of TR post-implantation. Methods We searched electronic databases from inception to January 2023 for published studies that reported incidence of TR worsening post-device implantation. Log odds ratio was used to summarize group differences. Results Our analysis included 29 studies with 66,590 participants. Patients with device implantation (n=1,008) were significantly more likely to develop worsening TR when compared with controls (n=58,605) (OR: 3.18, p<0.01). Amongst a total of 7,777 patients, pooled incidence of at least one-degree worsening of TR post-implantation was 23%. Worsening TR post-implantation significantly increases mortality (HR 1.42, p=0.02). Larger right atrial area (OR 1.11, p<0.01) is significantly associated with an increased risk of worsening TR post-implantation, while males are less likely to develop this complication when compared to females (OR 0.74, p<0.01). Importantly, there is no statistically significant difference between the type of implanted device (ICD vs PPM) and post-device TR. Further, RV dysfunction, pulmonary artery pressure, baseline mitral regurgitation, LVEF, baseline atrial fibrillation, and age have no association with worsening TR post-implantation. Conclusion A substantial number of patients undergoing PPM or ICD implantation are at an increased risk of worsening TR. Importantly, in this largest review to date incorporating over 66,000 subjects, this significantly increases mortality by greater than 140%, accordingly deserving more recognition and clinical attention in the current era.