Background

Pacemaker (PM) implantation after surgical or transcatheter tricuspid valve (TV) repair or replacement may be challenging. Surgical lead placement is a favorable option but still remains an invasive approach. Transcatheter leadless pacemaker (LPM) implantation has become a routine procedure and is frequently adopted in patients without the need for an atrial lead, in cases with cardiac implantable device infection or in patients with marked comorbidities aiming in reduction of periprocedural or long-term device-related complications. The use of LPM in patients with previous TV repair or replacement has only been described in singular cases in literature. We present our single center experience of LPM implantation after TV repair.

Methods

Patients with a history of TV repair or replacement who underwent LPM in our institution between 01/2020 and 06/2021 were retrospectively analyzed. All patients underwent routine clinical follow-up investigations including LPM interrogation and transthoracic echocardiography to assess for TV status. For LPM implantation right anterior oblique (RAO) and left anterior oblique (LAO) caudal fluoroscopy projections were utilized to enable LPM device passage across the TV (Figure 1).

Results

The study population consisted of 6 patients (5 females, mean age 72.8±11.9 years).

One patient had a history of surgical tricuspid valve annuloplasty repair, two patients of transcatheter TV annuloplasty repair, one patient of surgical TV bioprosthesis replacement and two patients of transcatheter bioprosthesis implantation (1 valve-in-ring implantation, 1 self-expanding nithinol-frame based valve system in a patient with preexisting pacemaker via a persistent left superior vena cava). All except one patient suffered from high-degree AV block, the remaining individual from symptomatic sinus node disease. The mean left ventricular ejection fraction previous to LPM implantation was 38.0±17.1 %. All six patients suffered from atrial fibrillation previous to implantation procedures.

A LPM system was successfully implanted in all six cases. The mean procedure time was 45.2±12.5 minutes with a mean fluoroscopy time of 7.8±5.7 minutes. The LPM device was positioned in the first positioning attempt in a right ventricular high septal localization in 5 patients. In the remaining patient the LPM device was positioned in the RVOT after 3 previously failed positioning attempts. Mean pacing threshold, sensing amplitude and pacing impedance at the end of the procedures was 0.4±0.1 V/0.25 ms, 9.5±2.6 mV and 717±209 Ohms, respectively. No periprocedural complications occurred.

All patients survived after after a mean follow-up of 11.7±9.0 months. There was no newly developed TV regurgitation noted. Pacing thresholds (0.4±0.1 V/0.25 ms), sensing amplitude (10.9±4.3 mV) as well as pacing impedances (690±258 Ohms) remained stable during the follow-up period.

Conclusion

LPM implantation was feasible in patients with a history of surgical or transcatheter TV repair or replacement. LPM may overcome limitations of conventional pacemaker implantations as well as surgical lead placement in selected patients.