Leadless pacemaker implantation following recent transcatheter tricuspid valve replacement: feasibility, challenges, and case review
J Gencher, A Raymond-Paquin, B MondesertAbstract
Introduction
Conduction disturbances, including atrioventricular (AV) block, are complications of transcatheter tricuspid valve replacement (TTVR), often necessitating permanent pacing1. Little has been described regarding the challenges of pacemaker implantation after recent TTVR. Traditional transvenous pacemaker systems pose a risk of disrupting the newly implanted tricuspid valve prosthesis. As a result, leadless pacemaker (LP) systems have emerged as a preferred alternative2. When the need for pacing is anticipated, LP implantation is typically performed prior to TVI to avoid potential disruption of the prosthetic valve and to simplify procedural logistics. In cases where conduction abnormalities arise post-procedure, delayed implantation introduces unique technical challenges.
Methods
We conducted a review of the existing literature describing LP implantation following recent TTVR, with emphasis on procedural feasibility, risks, and technical considerations3,4. In addition, we present a cases series from our own center where LP implantation was performed after recent (within 30 days) TTVR.
Results
432 patients had LP systems implanted at our center between January 2017, and June 2025. Of these, 8 patients had recent TTVR, 7 of whom had an LP implanted during the index hospitalization, and 1 who presented after discharge. LP implantation was performed under deep sedation. The LP system was delivered via the right femoral vein in 7, and the right internal (IJ) jugular in 1 patient, with transesophageal echocardiographic (TEE) and fluoroscopic guidance in all cases. Use of the right IJ in a patient undergoing TriClip allowed a more favourable angle of approach to cross the valve at the level of the posteroseptal commissure. Given the prosthesis, mid-to-apical septal position was targeted, with industry standard pacing, sensing, and system attachment thresholds. Mean fluoroscopy time was 289.3 µGy/m2 (5.3 minutes). Mean length of stay from implant to discharge was 2.8 days. There were no procedural complications related to LP implantation. Device parameters remained stable at most recent follow-up for all patients. Few published cases exist of LP after recent TTVR. Published cohorts do not specify the timing of LP implantation relative to TTVR and consist of either fewer patients than our center, or experience with only a single type of TTVR or LP device5.
Conclusion
LP implantation after TTVR is feasible but requires careful planning and intraprocedural imaging to avoid interference with the valve prosthesis. Challenges include altered cardiac anatomy, limited maneuverability, and risk to prosthesis integrity. Despite this, our review and case experience suggest that LP implantation is safe and feasible with appropriate expertise. These findings support the need for multidisciplinary planning in timing pacemaker implantation and highlight the need for further data to guide optimal management strategies in this emerging clinical scenario.