Background:

Patients suffering from cardiac sarcoidosis are at increased risk of ventricular arrhythmias as well as the risk for conduction disturbances such as complete atrioventricular block (AV block). Here we describe the case of a young adult patient requiring re-implantation of a pacemaker and an implantable cardioverter defibrillator (ICD) system after tricuspid valve reconstruction due to a device related endocarditis by a prior implanted transvenous dual-chamber ICD.

Case Summary:

A 41-year old female patient with cardiac sarcoidosis, who two months ago received a transvenous dual-chamber ICD for intermittent AV block and high risk of sudden cardiac death, presented with device and lead infection. The tricuspid valve was involved. Blood culture samples were positive for Staphylococcus aureus. The dual-chamber ICD was successfully explanted without any peri-operative complications. Due to severe destruction and regurgitation of the tricuspid valve, a surgical valve reconstruction with implantation of a 28mm CE-Tricuspid-Physioring was performed. A trace tricuspid valve insufficiency was reported. Postoperatively the patient presented a complete permanent AV block. Considering the young patients age, the elevated infection risk of transvenous leads as well as the necessity of further magnetic resonance imaging for the sarcoidosis, the implantation of epicardial or transvenous leads was avoided. An Atrial synchronous ventricular inhibited (VDD) leadless pacemaker was inserted. The implantation of Micra-AV (Medtronic TPS) through the reconstructed tricuspid valve proved to be challenging but feasible with no peri-operative complications. The procedural time and dose area product did not differ from routine parameters. Two month later a subcutaneous ICD (Boston Emblem A209) was implanted for primary prevention of sudden cardiac death in a third procedure. During Follow-up the patient presented with a high degree of AV-synchronous ventricular VDD-pacing (68%). No interaction between the leadless pacemaker and the subcutaneous ICD function were noticed.

Conclusion:

This case shows the safety and feasibility of leadless VDD pacemaker implantation through a reconstructed tricuspid valve. Combining the leadless VVD pacemaker with the subcutaneous ICD showed no interference between both systems. This combination may be considered in selected patients after device related infection.

Fig. 1 Implantation of a leadless VDD-pacemaker through a reconstructed tricuspid valve

Fig. 2 Chest X-Ray showing a leadless VDD-pacemaker and a subcutaneous ICD

Fig. 3 VDD-pacemaker (Medtronic MicraAV TPS) rate histogram showing different pacing and sensing portions