Permanent pacing via coronary sinus after tricuspid valve replacement: Keep bipolar coronary sinus leads on hand!

Conduction disturbances requiring permanent pacemaker (PPM) implantation are common after tricuspid valve replacement (TVR). Conventional transvalvular right ventricular pacing carries a risk of prosthetic valve dysfunction, whereas epicardial pacing is limited by surgical complexity, high pacing thresholds, and reduced lead durability. Coronary sinus (CS) pacing represents a potential alternative; however, data following TVR remain limited.

We retrospectively analyzed eight patients who underwent PPM implantation via the CS after TVR at our center. Demographic characteristics, procedural details, and pacing parameters were collected. Electrical performance (pacing threshold, lead impedance, and pacing percentage) was assessed during follow-up.

PPM implantation via the CS was successfully performed in all patients (median age: 61 years; 87.5% female). Seven patients underwent bioprosthetic TVR and one underwent mechanical TVR. The median interval between surgery and PPM implantation was 7 days. Mean procedure and fluoroscopy times were 66.5 ± 25.2 min and 13.3 ± 6.8 min, respectively. No acute or periprocedural complications occurred. During a median follow-up of 20.5 months, pacing thresholds and lead impedance remained stable (median threshold: 1.5 V, IQR: 1.0-2.25; median impedance: 846 Ω, IQR: 470-979), with a median ventricular pacing percentage of 82%. No lead-related complications were observed.

CS pacing is a feasible and safe strategy for patients requiring PPM implantation after TVR, providing stable electrical performance while avoiding the risks associated with transvalvular and epicardial leads. This approach may be particularly valuable in patients with mechanical prostheses and should also be considered in selected bioprosthetic valve recipients. Larger studies are required to confirm long-term outcomes.