Alternative Pacing Strategies Following Transcatheter Tricuspid Valve Interventions: Procedural Challenges and Lessons Learned.

Background: Decision making regarding new pacemaker implantation following transcatheter tricuspid valve intervention (TTVI), including transcatheter edge-to-edge repair (TEER) or transcatheter tricuspid valve replacement (TTVR), is complex due to anatomic and TTVI-related challenges.

Objective: To evaluate the feasibility of non-transvalvular pacing strategies including coronary sinus (CS) or leadless pacemaker (LP) placement, following TTVI.

Methods: Consecutive patients undergoing TTVI at a single institution were retrospectively studied for new pacemaker indications and pacing strategy. Procedural challenges and outcomes associated with non-transvalvular pacemaker implantation were assessed.

Results: Among 137 patients who underwent TTVI (69 TTVR, 68 TEER) at a single center, 34 (25%) patients were excluded for pre-existing pacemaker, and 15/103 (15%) patients subsequently developed an indication for pacing following TEER (n=5/53, 9%) or TTVR (n = 10/50, 20%). An alternative pacing strategy was attempted after TEER and TTVR. After TEER (n=5), CS lead placement was 50% successful (2/4) and one LP attempt was unsuccessful (0/1). After TTVR (n=10), CS lead placement was 75% successful (6/8) and LP placement was 100% successful (2/2) on initial attempt. CS lead placement was limited by CS anatomy, whereas LP placement was limited by TTVR interaction. A transvenous pacemaker was successfully placed if needed. No pacemaker device-related adverse event occurred in any patient peri-procedurally or at one year follow-up.

Conclusion: Alternative non-transvalvular pacing strategies may be feasible and safe in patients who require pacing following TTVI. Pre-procedural planning with a multidisciplinary approach can help optimize procedural success. Further studies and longer-term follow-up are warranted.