X-ray guided left bundle branch area pacing lead implantation after transcatheter tricuspid valve replacement is feasible and safe

Abstract Introduction AV-block is a common complication after transcatheter tricuspid valve implantation (TTVI) and pacemaker implantation can be challenging. Clinical experience using conduction system pacing (CSP) after TTVI is scarce. Purpose We describe a case series of CSP implantations guided by multiplanar imaging using x-ray following TTVI. Methods Pacemaker implantation was performed according to the latest EHRA guidelines and EHRA clinical consensus statement on CSP implantation. (1,2) A central position of the dedicated 3-dimensional CSP sheath and guide wire at the atrial site of the valve prosthesis was confirmed by x-ray in 2 planes in order to obtain proper longitudinal and axial alignment with the valve prosthesis (Figure 1). Advancing the CSP sheath over the guide wire allowed atraumatic crossing of the valve prosthesis and prevented entanglement in the metallic struts. Left bundle branch area (LBBA) lead implantation was aimed at least 5mm distal to the ventricular valve prosthesis cage. To avoid leaflet restriction final lead slack was judged in RAO ~30°. Results Patient 1 (82 years, male) suffering from advanced cardiac amyloidosis (LVEF 25%) underwent TTVI due to severe secondary tricuspid regurgitation (TR). Months later he developed poorly tolerated atrial fibrillation (AF) and a pace and ablate strategy was pursued. A left optimized cardiac resynchronization (LOT-CRT) pacemaker was implanted prior to AV-nodal ablation resulting in a paced QRS of 122ms. The patient died due to progressive heart failure 2 years later without lead or valvular dysfunction. Patient 2 (81 years, male) with permanent AF and mildly reduced left ventricular function underwent CSP implantation due to complete heart block following combined transcatheter aortic valve implantation and TTVI. CSP lead performance was stable with proper function of the tricuspid valve prosthesis at 3 months follow up. Patient 3 (61 years, female) with post-actinic valvular cardiomyopathy and replaced mitral and aortic valve underwent TTVI because of progressive symptomatic TR. Due to post interventional persistent complete AV-block a CSP pacemaker was implanted. Valvular function as well as CSP lead performance was favorable at 3 months follow-up. Patient 4 (85 years, female) with permanent AF and preserved ejection fraction developed a severe secondary TR due to annular dilatation and leaflet retraction. A complete AV-block following TTVI triggered an implantation of a CSP pacemaker in LBBA position. The tricuspid valve was free of relevant stenosis or regurgitation and CSP lead showed stable function at short-term follow up. Conclusions X-ray guided CSP lead implantation in LBBA position after TTVI is feasible and safe. Valve prosthesis function seems unaffected and lead function stable during short-term follow-up. There is a need for further studies with long-term follow up to prove safety of CSP and proper valve prosthesis function after TTVI.Peri-interventional X-ray's Paced QRS complexes