Special considerations in ventricular pacing in patients with tricuspid valve disease

Case presentation: implantation of cardiac resynchronization therapy pacemaker via the coronary sinus in a patient with triple valve replacement

Background

In patients with triple valve replacement developing third-degree atrioventricular block (AVB), the most appropriate approach for permanent pacemaker implantation remains questionable.

Case presentation

In this case presentation, we first described the approach of implantation of the cardiac resynchronization therapy pacemaker (CRT-P) via one bipolar pacing lead in middle cardiac vein (MCV) and one quadripolar pacing lead in anterior interventricular vein (AIV) in a patient developing complete AVB, who had been previously diagnosed with rheumatic valvular heart disease with triple valve replaced. After the CRT-P implantation, the two pacing leads in coronary sinus (CS) provided a dual-site ventricular pacing from the anterior septum and posterior septum, which resulted in a narrow QRS complex and an increased ventricular synchrony. During the long-term follow-up, no deterioration of heart function was documented and pacing parameters remained good.

Conclusion

In this patient developing complete AVB with triple valve replaced, our approach of CRT-P implantation provides an effective and reliable ventricular pacing, and is an alternative option when transvenous right ventricular pacing, transseptal left ventricular pacing and transpericardial epicardium pacing are not possible. Further prospective randomized trials are required to confirm the efficiency of our approach of dual-site ventricular pacing by CRT-P in this kind patients.

Left Ventricular Pacing through Coronary Sinus Is Feasible and Safe for Patients with Prior Tricuspid Valve Intervention

BACKGROUND

In the presence of tricuspid valve intervention, right ventricular lead implantation is associated with the potential risk of tricuspid valve malfunction leading to a tricuspid regurgitation. Few cases have been reported with successful left ventricular pacing via the coronary sinus (CS) after tricuspid valve replacement or repair. In this retrospective study, we present the long-term clinical outcomes of 17 patients who underwent CS lead implantation and left ventricular pacing.

METHODS

Seventeen consecutive patients referred to our institution with an indication of postprocedural pacemaker (PM) implantation after tricuspid valve intervention were retrospectively included in the study. The indication for device implantation in all patients was atrial fibrillation with a symptomatic pause ≥ 3.0 seconds. Thus, all devices implanted were ventricular rate responsive (VVIR).

RESULTS

All device implantations were successful and uncomplicated. Mean operation time was 60 ± 8 minutes. Mean fluoroscopy time was 8.3 ± 2.1 minutes. Mean R-wave sensing was 7.5 ± 2.0 mV with a mean slew rate of 2.2 V/s. A mean pacing threshold of 1.9 ± 0.3 V/0.4 ms was accepted as patients were not PM-dependent. The pacing impedance was 743.5 ± 109.71 Ohm. At 2-year follow-up, pacing sensing, threshold, and impedance values were unchanged and no lead dislodgement has been noted.

CONCLUSIONS

In patients with tricuspid valve intervention, left ventricular pacing might be the treatment of choice for permanent ventricular pacing, with all the advantages of the endovenous route as a minimally invasive approach.

Permanent pacing in a patient with tricuspid prosthesis--widening therapeutic use of coronary sinus

Unconventional sites are being used for pacing in patients with inaccessible right ventricle like single ventricle, atresia of tricuspid valve and in anomalous venous drainage. Here we report a case in which the right ventricle could not be accessed due to the metallic prosthesis. A 41-year-old lady required triple valve replacement for rheumatic involvement. Permanent pacemaker implantation was done with epicardial lead for bradycardia post operatively. Pulse generator change was needed within 3 years as the pacemaker reached end of life due to high lead threshold. Subsequent pacemaker implantation was done with a left ventricular lead in coronary sinus by percutaneous approach. One year after implantation, the threshold remains stable. Coronary sinus can be utilized for permanent pacing in patients with inaccessible right ventricle due to prosthetic tricuspid valve.

Transvenous right ventricular pacing in a patient with tricuspid mechanical prosthesis

We report a patient in whom permanent endocardial pacing was accomplished by passage of the electrode through a mechanical tricuspid valve. Echocardiography study showed a minimal tricuspid regurgitation.

Right Ventricular Endocardial Pacing with Tricuspid Valve Replacement

A novel technique for simultaneous tricuspid valve replacement and endocardial pacing is described. The technique was applied in a 67-year-old man who had previously undergone coronary artery bypass grafting and subsequent pericardiotomy via a left thoracotomy. He developed congestive heart failure due to tricuspid valve regurgitation as well as impaired left ventricular function with bradycardia. Endocardial pacing was successfully performed in conjunction with tricuspid valve replacement using a bioprosthesis via a right anterolateral thoracotomy.

Permanent pacing in patients with tricuspid valve replacements

OBJECTIVE

To assess the incidence and complications of permanent pacing in patients who undergo tricuspid valve replacement.

DESIGN

A retrospective study of records of patients who had a tricuspid valve replacement between 1978 and 1993 at the Middlesex hospital.

RESULTS

45 patients with tricuspid valve replacements were followed up for a total of 104 patient years. Ten patients (22%) required permanent pacing, five with epicardial leads and five with endocardial. Endocardial leads had significantly lower initial implantation thresholds and were associated with fewer complications.

CONCLUSION

Patients undergoing tricuspid valve replacement frequently require permanent pacing. Endocardial or epicardial lead insertion should be considered at the time of tricuspid valve replacement.

Tricuspid valve repair for biopsy-induced regurgitation after cardiac transplantation

Tricuspid regurgitation is a recognized complication of cardiac transplantation. Damage to the tricuspid valve and subvalvar apparatus has been suggested as a possible cause. We have repaired the tricuspid valves of 2 patients in whom severely symptomatic tricuspid regurgitation developed after transplantation. Gore-Tex sutures were used to replace ruptured chordae anchoring the septal and posterior leaflets. The repair was supported with a Carpentier-Edwards ring. The repairs remain durable at 2 year and 3 years. Both patients demonstrated a similar lesion that we believe to be characteristic of endomyocardial biopsy-induced tricuspid regurgitation.

Endocardial pacing through a prosthetic tricuspid valve

We describe a patient in whom permanent endocardial pacing was accomplished by passage of the electrode through a porcine bioprosthetic tricuspid valve, thereby obviating the need for a second thoracotomy. After 8 years of follow-up, the patient continues to do well with satisfactory pacing and bioprosthetic valve function at the first change of pulse generator.