Implantation of leadless pacemaker through neo-orifice after tricuspid valve edge-to-edge repair

We present a case of a 71-year-old female with dilated cardiomyopathy, bradycardic permanent atrial fibrillation, and complete right bundle branch block, who underwent leadless pacemaker (LPM) implantation (Micra, Medtronic Inc.) after edge-to-edge tricuspid valve repair for severe functional tricuspid regurgitation with three MitraClips XTR (Abbott Inc.) deployed. A possible worsening of tricuspid regurgitation triggered the decision to reject a conventional ventricular lead implantation. Leadless pacemaker implantation was guided using three-dimensional transoesophageal echocardiography (3D TOE) in order not to damage the repaired valve with the large delivery catheter (Cath) (Panel A). Two tricuspid valve neo-orifices (NOs) formed after clip implantation were visualized for adequate steering of the delivery catheter. Initially, the delivery catheter was introduced through the larger NO-1 [1.6 cm2, between posterior and anterior (AL) leaflets]. However, limited steering led to unsuitable LPM positions with high threshold values. Under strict 3D TOE guidance, the delivery catheter was then withdrawn and reintroduced through the smaller NO-2 (0.6 cm2, between septal leaflet and AL), which led to optimal septal-apical LPM positioning with acceptable threshold value of 0.25 V/0.24 ms (Panel B). Severity of pre-existing moderate residual tricuspid regurgitation remained unchanged. Leadless pacemaker implantation after edge-to-edge tricuspid valve repair is feasible but can be challenging in terms of limited steering of the delivery catheter; however, 3D TOE guidance helps with safe and effective steering through tricuspid valve NOs. The full-length version of this report can be viewed at: https://www.escardio.org/Education/E-Learning/Clinical-cases/Electrophysiology.