Cardiac Implantable Electronic Devices and Transcatheter Tricuspid Valve Replacement With the EVOQUE System: A Case-Review Series Highlighting Procedural and Management Considerations

Severe, untreated tricuspid regurgitation is associated with worse clinical outcomes. While isolated tricuspid valve (TV) surgery has been linked to poor long-term outcomes, transcatheter TV therapies, including edge-to-edge repair and transcatheter tricuspid valve replacement (TTVR), have emerged as effective alternatives and have been shown to improve outcomes, leading to their regulatory approval in the United States. Conduction system abnormalities are commonly seen among patients undergoing TTVR due to the close proximity of the atrioventricular node and the His bundle to the TV annulus. In the TRISCEND II (Transcatheter Tricuspid Valve Replacement: Pivotal Clinical Investigation of Safety and Clinical Efficacy Using a Novel Device) trial, 38% of the patients had prior cardiac implantable electronic devices (CIEDs), while 25% of patients developed new conduction abnormalities necessitating implantation of new CIEDs. Concerns exist regarding trapping existing CIED leads during TTVR. Similarly, transvenous permanent pacemaker implantation post-TTVR has been reported to be associated with valve dysfunction. In this case-based narrative review, we describe case examples of patients with prior CIEDs undergoing TTVR and conduction abnormalities post-TTVR needing a new permanent pacemaker and discuss potential periprocedural strategies for optimal outcomes. Electrophysiologists specializing in periprocedural management of CIEDs, including lead extraction and post-TTVR device management, play a crucial role and should be part of a comprehensive heart team approach for optimal outcomes.