Valve It Right? Can Transthoracic Imaging Prevent CIED-Induced Tricuspid Regurgitation?

The subcostal en face view of the tricuspid valve has emerged as a promising echocardiographic technique for visualizing right ventricular (RV) lead positions in patients with cardiac implantable electronic devices (CIEDs). This approach offers the potential to prevent tricuspid regurgitation (TR) by allowing rhythmologists to adjust lead positions in real time, ensuring optimal device placement and minimizing valve interference. A study by Zach et al. (2024) demonstrated the feasibility of this technique in 64% of patients, offering a viable alternative when 3D echocardiography is unavailable or non-diagnostic. The study found no significant correlation between lead position and TR severity, suggesting that other factors may contribute to TR development. While the subcostal en face view holds significant promise, limitations such as poor image quality in patients with obesity, abdominal pathologies, or multiple leads, as well as the need for experience to maximize success rates, must be addressed. Future prospective studies are needed to validate the clinical benefits of the subcostal en face view during CIED implantation, including its impact on procedural duration and TR prevention. This technique represents an important step toward enhancing patient safety and improving CIED implantation protocols.