Leadless pacemaker implantation after transcatheter tricuspid valve replacement: first experiences and safety of the jugular approach

Background

Transcatheter tricuspid valve replacement (TTVR) has gained increasing importance in recent years. Approximately 10% of patients subsequently develop high-grade atrioventricular (AV) block requiring pacemaker implantation. Four options are available for treatment: a leadless pacemaker, an epicardial lead, a coronary sinus lead, or a transprosthetic transvenous lead. Leadless pacemakers (LLP) are promising because they eliminate the need for transvenous electrodes, are less invasive, carry a lower risk of valve interaction and allow early postoperative mobilization. Since TTVR is a relatively new procedure, experience with LLP remains limited. Leftward-angulated valve prostheses may complicate implantation, whereas the jugular approach provides a more direct route into the right ventricle.

Methods

In our prospective registry study, all patients requiring pacemaker implantation after interventional TTVR between October 2024 and October 2025 were included. The procedure was performed in a caudally angulated left anterior oblique (LAO) projection. LLP function was evaluated immediately postoperatively, on the following day, and after one month.

Results

Five patients were included in the analysis. The mean age was 80±7 years, and the majority were female (n=4). Indications for pacing were high-grade AV block (60%) or bradyarrhythmia absoluta (40%). The mean procedure time was 61±20 minutes, fluoroscopy time 18.5±7.4 minutes, and radiation dose 1216±797 cGy·cm². All implantations were successfully performed via the transjugular approach.

Valve–device interaction occurred in two cases. In the first, the helix became entangled in the frame of the valve prosthesis, necessitating device replacement (Fig. 1). In subsequent implantations, the protective sleeve was advanced to its maximum position, after which no further helix–frame interactions occurred. One case of protective sleeve perforation was observed, without clinical or functional consequences (Fig. 2). No additional perioperative complications occurred.

Electrical parameters remained stable. The pacing threshold was 0.80±0.34V/0.4 ms postoperatively, 0.70±0.31V/0.4 ms on the first postoperative day (p=0.18), and 0.55±0.28V/0.4ms after one month (p=0.10). Impedance was 670±110Ω postoperatively, 702±95Ω on day 1 (p=0.47), and 574±80Ω after one month (p=0.31). Sensing amplitudes were 6.24±2.1 mV postoperatively, 7.33±2.8mV on day 1, and 12.74±4.3mV after one month (p=0.13).

Conclusion

Valve interaction remained with no clinical consequences. Interaction between the helix of the LLP and the valve frame can be minimized by fully advancing the protective sleeve. Considering the risks of conventional strategies, the transjugularly implanted leadless pacemaker represents a promising alternative following TTVR. Further studies with larger patient populations and longer follow-up are needed to confirm long-term outcomes and clinical efficacy.