CONGRESS ABSTRACT

INTRODUCTION: Leadless pacemakers (LP) have been proven to be an effective pacing option after tricuspid valve intervention. Nevertheless, the optimal pacing modality in patients with a tricuspid valve stenosis is still debated. CASE REPORT: An 86-year-old man with a mechanical aortic valve and a biological tricuspid prosthesis since 2009 was admitted to our department for recurrent syncopal episodes and worsening dyspnea (NYHA III). He was affected by permanent atrial fibrillation, chronic kidney disease and high frailty. Clinical examination showed signs of heart failure with good hemodynamic parameters. An echocardiogram revealed a normally functioning prosthetic aortic valve, degeneration of the biological prosthesis with severe tricuspid stenosis, and significant periprosthetic leakage along the septal leaflet of the valve. ECG monitoring showed evidence of atrial fibrillation with bradyarrhythmia (minimum daytime HR of 35 bpm). He started diuretic therapy with a good clinical response. Due to his high frailty and prohibitive surgical risk, surgical or percutaneous valvular intervention was excluded. In order to avoid compromising the tricuspid valve apparatus with a transvenous catheter and to limit the patient’s risk of infection, we decided to implant a LP. Despite the complexity in accessing the right ventricle due to the presence of severe tricuspid stenosis, the device was released in the apical septal area with excellent electrical parameters and good stability, in the absence of significant interactions with the prosthetic valve apparatus. A few days later he was discharged in good clinical condition. At follow-up the patient reported no syncopal recurrences with improvement in functional class (NYHA II). CONCLUSION: The optimal pacing strategy in patients with bioprosthetic tricuspid valve stenosis should not include transvalvular lead implantation, due to the possible deleterious effect on bioprosthetic valve function. The most used option in high surgical risk patients is the implantation of a ventricular catheter in the coronary sinus. Although this is an efficient method, it performs less well than endocardial pacing, especially in patients who have already undergone open-heart surgery, which may lead to difficulties in identifying a site with a good pacing threshold. This case report seems to support the feasibility and safety of LP implantation, with a low risk of infection and without involvement of the valve orifice over time.