Safety and Feasibility of Left Bundle Branch Area Pacing Following Transcatheter Tricuspid Valve Replacement

Figures

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  Figure 1. Electrocardiographic and Echocardiographic Findings Before and After Transcatheter Tricuspid Valve Replacement and Left Bundle Branch Area Pacing in Patient 1 (A) Sinus rhythm with 2:1 atrioventricular block. (B) Left bundle area pacing (rSR' pattern in lead V1). (C) Echocardiographic evolution of TR before and after TTVR and PPM implantation. Left panel: baseline transthoracic echocardiography demonstrating severe TR, with a large color Doppler regurgitant jet and dense continuous-wave Doppler signal (EROA: 0.81 cm2, regurgitant volume: 33 mL). Middle panel: Immediately post-TTVR and before pacemaker implantation, TR severity is reduced to mild, as evidenced by smaller jet area and lower Doppler velocity. Right panel: at 1-month follow-up after TTVR and PPM, TR remains mild with stable hemodynamics and no significant increase in regurgitant jet or spectral Doppler signal. EROA = Effective Regurgitant Orifice Area; PPM = permanent pacemaker; TR = tricuspid regurgitation; TTVR = transcatheter tricuspid valve replacement.

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  Figure 2. Electrocardiographic and Echocardiographic Findings Before and After Transcatheter Tricuspid Valve Replacement and Left Bundle Branch Area Pacing in patient 2 (A) Complete heart block with junctional bradycardia and incomplete right bundle branch block. (B) Left bundle area pacing (QR pattern in V1, discordant polarity in leads II and III). (C) Serial echocardiographic assessment of TR before and after TTVR and PPM implantation. Left panel: Baseline transthoracic echocardiography demonstrates severe TR with a large color Doppler jet, vena contracta width, and dense continuous-wave Doppler signal (EROA: 0.47 cm2, regurgitant volume: 70 mL). Middle panel: immediately after TTVR and before pacemaker implantation, only mild residual TR is noted with markedly reduced jet size and lower Doppler velocity profile. Right panel: at 1-month follow-up after TTVR and PPM, trace residual TR is observed with near-complete resolution of regurgitation by both color Doppler and spectral Doppler interrogation. Abbreviations as in Figure 1.

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  Figure 3. Fluoroscopic View (Right Anterior Oblique and Left Anterior Oblique) Demonstrating the TTVR In Situ A left bundle branch area pacing lead is positioned along the interventricular septum, and a right atrial lead is visualized in the right atrial appendage as labeled. LBAP = left bundle branch area pacing; RA = right atrial; other abbreviations as in Figure 1.