Trans-oesophageal echocardiography-guided implantation of a cardiac resynchronization therapy pacemaker and successful ablation of the atrioventricular node after TriClip: case report

Figures

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  Figure 1. Tricuspid regurgitation. The image on the left side (A) demonstrates the patient’s massive tricuspid regurgitation prior to TriClip treatment. After the TriClip procedure (Image B) regurgitation was reduced; the open arrow indicates the TriClip. The image on the right side (C) is taken after cardiac resynchronization therapy pacemaker (CRT) implantation and shows unchanged mild tricuspid regurgitation, with the TriClip in unchanged position. The solid arrow points to the right ventricular lead. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.

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  Figure 2. 3D echocardiography during pacemaker implantation (trans-gastric and deep oesophageal 3D images). Images A and B present the initial situation with the right ventricular lead spontaneously taking an anterior path in trans-oesophageal 3D images. As this would interfere with the previously implanted TriClip, and would complicate later AV node ablation, the right ventricular lead was repositioned in the postero-septal commissure. The left ventricular lead was advanced via the coronary sinus to its final position (trans-oesophageal 3D images C and D). As the left ventricular lead was positioned anterior to the right ventricular lead, the left ventricular lead pushed the right ventricular lead closer to the postero-septal commissure, securing the right ventricular lead’s position.

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  Figure 3. Fluoroscopy during pacemaker insertion and electrocardiogram (ECG) after electrophysiology treatment. Image A shows the relationships between the pacemaker leads and the TriClip in the left anterior oblique fluoroscopy image taken during the pacemaker implantation. In Image B, the position of the ablation catheter is shown in relation to the TriClip and pacemaker leads. Image C shows patient’s ECG (25 mm/s) taken immediately after atrioventricular node ablation showing simultaneous right ventricular and left ventricular pacing with a QRS duration of 122 ms.