Post-TAVI atrioventricular block: navigating the triple jeopardy of tricuspid regurgitation, pacemaker-induced heart failure, and left innominate vein obstruction.

Transcatheter aortic valve implantation (TAVI) has become a widely accepted therapeutic intervention for severe aortic stenosis, but it is frequently complicated by the development of atrioventricular block (AVB) that requires pacemaker implantation. This case report aims to present a 66-year-old male who developed a high-grade AVB after TAVI, requiring implantation of a dual-chamber pacemaker. Post pacing implantation, the patient presented with symptoms of heart failure (HF) and two-dimensional echocardiogram revealed severe tricuspid regurgitation (TR) and reduced left ventricular systolic function. Despite attempts to upgrade the pacemaker to a biventricular system, complications arose due to venous obstruction of the left brachiocephalic vein, which was overcome by tunneling the left ventricular lead from the right side. The patient achieved complete resolution of HF symptoms and marked improvement in both TR and left ventricular function after upgrading. This case illustrates the "triple jeopardy" of post-TAVI complications: pacemaker-induced HF, worsening of TR, and venous obstruction. It underlines the importance of thorough assessment of the patient and innovative management strategies for optimum results. The successful lead-tunneling techniques could become a solution for similar cases of venous obstruction when pacemakers are being replaced. Whereas TAVI saves life, management of complications such as AVB and TR with utmost care would prevent morbidity and enhance long-term outcome. This case emphasizes on the need for continuous monitoring post-TAVI and guided intervention that addresses both pacemaker-induced and venous complications.