Valve‐Sparing Pacing Strategies After Tricuspid TEER: An Imaging‐Guided Case Series

BACKGROUND: Permanent pacing after tricuspid transcatheter edge-to-edge repair (TEER) may be technically challenging due to the risk of interaction between pacing systems and repair devices. Evidence guiding optimal pacing strategies in this setting remains limited. METHODS: We report a single-center case series of three patients with previous tricuspid TEER who required permanent pacing. Device selection and procedural planning were guided by multimodality imaging, including transesophageal echocardiography (TEE) and intracardiac echocardiography (ICE). Valve-sparing pacing strategies were selected according to individual clinical characteristics. RESULTS: Two elderly patients underwent implantation of a leadless pacemaker, while a third patient with dilated cardiomyopathy underwent left bundle branch area pacing (LBBAP) during cardiac resynchronization therapy upgrade. Imaging guidance allowed safe traversal of the repaired tricuspid valve while avoiding mechanical interaction with the TEER devices. All procedures were successful, with stable pacing parameters and no procedural complications. Tricuspid regurgitation remained unchanged in all patients during follow-up. In the patient undergoing LBBAP, left ventricular ejection fraction improved from 30% to 57% at 6 months. CONCLUSIONS: Valve-sparing pacing strategies guided by multimodality imaging appear feasible and safe in patients with prior tricuspid TEER. Leadless pacemakers and conduction system pacing represent complementary options that can be tailored to individual clinical profiles.