Echocardiographic assessment after left bundle branch area pacing: impact on the tricuspid valve apparatus, clinical value and perspectives
T Barre, R Pierrard, A N N E Suzat, N Benguella, R Mohammed, G Bayard, K Azarnouch, N Grand, M Murat, M Bouhkris, K Benali, A Da CostaAbstract
Background
Cardiac implantable electronic device (CIED) leads are known to interact with the tricuspid valve apparatus (TVA) and are associated with tricuspid regurgitation (TR). In this context, physiological pacing strategies—particularly left bundle branch area pacing (LBBAP)—seem to better preserve left ventricular (LV) function; however, their impact on the TVA and their clinical value have not yet been investigated.
Objectives
This prospective study aimed to: (1) compare the impact of LBBAP and right ventricular apical pacing (RVAP) on TVA lead-crossing localization; (2) evaluate the incidence of new-onset lead-induced TR (LITR) or worsening of preexisting TR (WTR); and (3) assess the early impact of pacing type on LV remodeling and peak longitudinal strain dispersion.
Methods
This study included consecutive patients undergoing either traditional RVAP or LBBAP lead implantation between October 2024 and October 2025. Comprehensive three-dimensional transthoracic echocardiography (3D TTE) was performed within 24 hours before and the day after CIED implantation in order to evaluate the impact of pacing modality on the TVA.
Results
A total of 115 patients were enrolled: 45 received LBBAP, 20 received an implantable cardioverter-defibrillator (ICD) [including 7 with cardiac resynchronization therapy (CRT)], and 50 underwent RVAP [including 7 with CRT]. Overall, 70 patients received an RVAP lead. Lead–leaflet impingement was observed in 49/115 patients (42.6%): 28/70 (40%) in the RVAP group and 21/45 (46.7%) in the LBBAP group (ns). In the LBBAP group, leads crossed the TV more frequently in the anterior area (19/45; 42%), whereas RVAP leads crossed more often in the posteroseptal area (50/70; 71.5%), (p = 0.025). In the FU, the incidence of new-onset LITR or WTR was low (8%, 5/66) but represented 19% (5/26) of patients with leaflet or commissural impingement identified on immediate post-implantation 3D TTE (p=0.016). No significant difference was found between both pacing groups (2 in RVAP, 3 in LBBAP). Moreover, LBBAP was associated with an immediate beneficial effect on indexed LV stroke volume (SVi), post-implantation global longitudinal strain (ΔGLS), and time-to-peak strain dispersion.
Conclusions
This is the first prospective study to demonstrate that LBBAP leads cross the tricuspid valve (TV) more frequently in the anterior area, whereas RVAP leads tend to cross in a posteroseptal position. Early worsening of tricuspid regurgitation (TR) after CIED implantation was uncommon but could be anticipated through early detection of leaflet or commissural impingement on three-dimensional transthoracic echocardiography (3D TTE). The long-term effects of LBBAP on the tricuspid valve apparatus (TVA) and TR remain to be established. Our findings support the use of systematic post-pacing echocardiographic monitoring to detect early complications and to better characterize lead–TVA interactions.Table 1-Population characteristicsLeads position scheme