PO-04-016 FIRST REPORT OF LEADLESS PACEMAKER IMPLANTATION IN A PATIENT WITH BOTH A TRANSCATHETER TRICUPID VALVE REPAIR (TRICLIP) AND SURGICAL TRICUSPID VALVE ANNULOPLASTY

Abstract

An increasing number of patients with valvular heart disease are undergoing novel structural valve interventions with subsequent need for pacemaker implantation. Leadless cardiac pacemakers (LCP) may be particularly suitable in patients with prior tricuspid valve interventions. However, the process of navigating previously repaired tricuspid valves (surgical or percutaneous) can be challenging. To our knowledge, implantation of an LCP in a patient with both surgical TV repair (annuloplasty) and transcatheter TV repair (TriClip, TTVr) has not been reported. In this case, intracardiac echocardiography (ICE) was used to navigate the LCP to its final implant position. To describe the feasibility of implanting an LCP in a patient with surgical and percutaneous tricuspid valve repairs, and the utility of ICE-guided implantation. N/A A 69 year old female with prior inferior vena cava (IVC) filter, percutaneous mitral valve repair (MitraClip) and transcatheter tricuspid valve repair (TriClip) underwent a BioBentall procedure with tricuspid valve repair (annuloplasty band). The existing clips were not removed at the time of surgery. She ultimately developed an indication for back-up ventricular pacing (intermittent high-degree AV block) and an LCP was recommended (Micra, Medtronic Inc., Minneapolis, MN). Under fluoroscopic guidance, the LCP introducer sheath (27 French outer diameter) was first traversed through the IVC filter into the right atrium. Then, using ICE to visualize the tricuspid valve and taking note of the clip position, the deflectable delivery system was maneuvered through the residual tricuspid valve orifice into the right ventricle while avoiding the clips via a superior and anterior approach. Positioning of the delivery system in the apical right ventricular septum in respect to the annuloplasty band and clips was confirmed on ICE imaging and fluoroscopy before and after deployment. LCP sensing, pacing threshold and impedance values were within normal limits. The severity of pre-existing moderate residual tricuspid regurgitation remained unchanged on follow up transthoracic echocardiography. Implantation of a leadless pacemaker after both transcatheter tricuspid valve repair and surgical tricuspid valve annuloplasty band is feasible. Steering through an anatomically challenging tricuspid valve neo-orifices can be performed safely and effectively under intracardiac echocardiography guidance.