Endocardial right ventricular (EnRV) leads are described as potential cause of native tricuspid valve regurgitation (TR). Need for cardiac pacing by EnRV or epicardial (EpiRV) lead after tricuspid valve repair (TVr) or bioprosthetic replacement (bTVR) is common, but little is known about their effects post-operatively. Assess clinical outcomes, such as TR, lead function, and risk of infection in patients with TV prosthesis followed by EnRV vs EpiRV lead implant. We retrospectively reviewed all patients with RV lead post-TVr or bTVR at our hospital between 1/2000-11/2022. These were divided in 2 groups: Grp 1 (patients with EnRV lead) and Grp 2 (patients with EpiRV lead). Primary outcome was change in TR and RV lead function at follow up. Level of TR was scored as 0 = none/trivial, 1 = mild, 2 = moderate, 3 = moderate-severe or severe. Pacing threshold change (Δ +/- SD V), need for revision/extraction, and death at follow up were noted. 64 patients were identified [Grp 1: n = 52 (56% female, 79% atrial fibrillation, 94% TVr, 6% bTVR) vs Grp 2: n = 12 (67% female, 42% atrial fibrillation, 42% TVr, 58% bTVR)]. In Grp 2, 58% had prior RV lead extracted intraoperatively due to lead-related TR vs 0% in Grp 1. In Grp 1, mean time from surgery to RV lead implant, last ECHO, and last device interrogation were 24, 77, and 83 months vs 0, 10.6, and 9 months for Grp2, respectively. TR worsened in Grp 1 only in 55% of TVr patients (mean 0.9 level). When compared to Grp 2, TR was significantly worse in Grp 1 vs Grp 2 (p = 0.029, FigA). This was particularly the case after TVr (FigB) and not bTVR (FigC). RV lead threshold significantly worsened in Grp 2 vs Grp 1 (55.5% vs 3.7%, p = 0.003); threshold increased significantly by Δ 1.18 +/- 2.05 V vs Δ 0.11 +/- 0.34 V (p = 0.026). Average threshold at follow up in Grp 2 was 2.02 +/- 2.13 V vs 0.737 +/- 0.27 V for Grp 1 (p = 0.05). Lead extraction occurred in 8% of patients in Grp 1 (25% endocarditis, 75% lead failure/malfunction) and 17% in Grp 2 (100% endocarditis). There were 28 deaths (Grp 1: 42%, mean follow up 97.9 months vs Grp2: 50%, mean follow up 14 months). In our study, presence of EnRV lead after TV surgery correlated with mild increase in TR after TVr but not bTVR. On the other hand, EpiRV lead threshold increased significantly over time compared to EnRV leads. EnRV lead is a suitable approach after TVr or bTVR.