title: The challenge of endocardial right ventricular pacing in patients with a tricuspid annuloplasty ring and severe tricuspid regurgitation.
abstract: On occasion, patients with a tricuspid annuloplasty ring may require permanent cardiac pacing. Although it is technically possible to pass a ventricular transvenous lead through a tricuspid valve with an annuloplasty ring, the procedure is complicated by considerable chamber enlargement and mechanical distortion of the tricuspid valve often with severe residual tricuspid regurgitation. Over a 25-month period, transvenous ventricular lead placement following insertion of a tricuspid annuloplasty ring was successfully performed in five patients (three women). The patient mean age was 66 years (range 55-77 years). Four cases had slow atrial fibrillation and another paroxysmal atrial fibrillation requiring His-bundle ablation. Two patients had mitral valve replacement and two aortic and mitral valve replacements. All patients had residual severe to torrential tricuspid regurgitation. Seven ventricular steroid-eluting screw-in leads were used. Single leads were used in three cases, whereas in two others, two ventricular leads were attached to a dual chamber pulse generator. Although technically difficult, ventricular lead placement was successful using standard guidewires with broad curvatures. Satisfactory acute and follow-up stimulation thresholds and sensing were obtained with the only complication being an intraoperative lead dislodgement, prompting a second ventricular lead. Successful transvenous lead placement across a tricuspid annuloplasty ring is possible.
authors.affiliation: Department of Cardiology, The Royal Melbourne Hospital, Victoria, Australia.
authors.forename: Peter M
authors.initials: PM
authors.lastname: Kistler
authors.forename: Prashanthan
authors.initials: P
authors.lastname: Sanders
authors.forename: Neil C
authors.initials: NC
authors.lastname: Davidson
authors.forename: Harry G
authors.initials: HG
authors.lastname: Mond
mesh_terms: D000368:Aged; D002304:Cardiac Pacing, Artificial / Q000379:methods*; D004567:Electrodes, Implanted; D005260:Female; D006801:Humans; D008297:Male; D010138:Pacemaker, Artificial; D014261:Tricuspid Valve / Q000601:surgery*; D014262:Tricuspid Valve Insufficiency / Q000628:therapy*