Transvenous lead implantation in a patient with mechanical prosthesis in the tricuspid position: Transvenous route should be the first choice

Abstract

A 36-year-old male patient with Ebstein's anomaly and severe aortic stenosis having two mechanical valve prostheses in the aortic and tricuspid valves was referred to our center for previously implanted pacemaker malfunction. Permanent pacemaker with VVI mode was implanted on the right ventricular apical epicardial surface using left thoracotomy because of complete heart block after valve surgery. After 1 year from implantation, however, another permanent pacemaker with VVI mode was implanted on the right ventricular free wall epicardial surface using right thoracotomy due to pacemaker malfunction with very high pacing threshold. Similarly, approximately 3 years after implantation very high pacing threshold was detected with complete heart block on surface ECG. Therefore we decided to implant a permanent pacemaker with DDD mode via transvenous route. After appropriate patient preparation double puncture was performed to the subclavian vein. First, coronary sinus was cannulated and a bipolar coronary sinus lead was implanted in the great cardiac vein with excellent pacing and sensing values (0.4 V of pacing threshold and 16 mV of R-wave amplitude). Second, a bipolar active fixation lead was implanted in the right atrial appendage region with excellent pacing and sensing values (0.3 V of pacing threshold and 6 mV of p-wave amplitude). Last, a permanent pacemaker with DDD mode was implanted in the left pectoral region with good atrioventricular synchronous pacing on surface ECG (Fig. 1 and Video). Extraction of remaining two pulse generators was postponed to a later date and no extraction of epicardial leads was decided to avoid the risks of surgery. Transvenous route should be the first approach to implant permanent pacemaker or implantable cardioverter–defibrillator in patients with mechanical prosthetic valve in the tricuspid position because surgical implantation needs a requirement of a thoracotomy which is associated with longer hospitalization period, and higher morbidity and mortality. In addition, epicardial implantation is associated with a higher incidence of lead failure as in our case [ [1] Cay S. Transvenous cardioverter–defibrillator lead implantation in a patient with three mechanical prosthetic valves: all in one solution. Int J Cardiol. 2013; 165: e33-4 Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar ].